Anatomy and Refractive Power of the Eye
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1
What are the two main divisions of the eyeball?
Anterior segment and posterior segment
2
What structure forms the boundary between the anterior and posterior segments?
Lens-iris diaphragm
3
Does the conjunctiva cover the cornea?
No, the cornea must remain transparent.
4
Where does the conjunctiva terminate?
Limbus, the corneoscleral junction
5
What is the limbus?
Junction between the cornea and sclera
6
What is the main function of the cornea?
Refracts light and transmits it into the eye
7
What are the two main refractive structures of the eye?
Cornea and lens
8
What is the total refractive power of the eye?
60 diopters
9
What is the refractive power of the cornea?
40–43 diopters
10
What percentage of focusing power does the cornea contribute?
Approximately 2/3 or up to 85%
11
What is the refractive power of the lens?
17–20 diopters
12
What percentage of focusing power does the lens contribute?
Approximately 1/3
13
What is the diameter of the adult cornea?
Approximately 11 mm
14
What is the vertical diameter of the cornea?
11 mm
15
What is the horizontal diameter of the cornea?
11.5 mm
16
What is the central corneal thickness?
Approximately 500 μm
17
What is the peripheral corneal thickness?
Approximately 650 μm
18
What is the approximate corneal thickness along its margins?
1 mm
19
What instrument measures central corneal thickness?
Pachymetry
20
What imaging technique can measure corneal thickness?
Optical coherence tomography (OCT)
21
What are the three main cellular layers of the cornea?
Epithelium, stroma, and endothelium
22
What are the two auxiliary acellular layers of the cornea?
Bowman's layer and Descemet's membrane
23
What are the five corneal layers from anterior to posterior?
Epithelium, Bowman's layer, stroma, Descemet's membrane, endothelium
24
What mnemonic represents the five corneal layers?
ABCDE
25
What is the order of the ABCDE corneal layers?
Anterior epithelium, Bowman's layer, central stroma, Descemet's membrane, endothelium
26
What is Dua's layer?
Thin pre-Descemet's layer anterior to Descemet's membrane
27
What makes the cornea transparent?
Uniform collagen arrangement, avascularity, lack of pigment, and deturgescence
28
Why is the sclera white?
Irregular arrangement of collagen fibers
29
What is corneal deturgescence?
Relative dehydration of corneal tissue
30
What is the vascular status of the normal cornea?
Avascular
31
What are the three nutritional sources of the cornea?
Limbal vessels, aqueous humor, and tears
32
Where does the cornea obtain most of its oxygen?
Atmosphere through the tear film
33
Which cranial nerve supplies corneal sensation?
Ophthalmic division (V1) of the trigeminal nerve
34
What is the central 5 mm of the cornea responsible for?
Most of the corneal refractive power
35
What type of epithelium covers the anterior cornea?
Stratified squamous nonkeratinizing epithelium
36
How many layers does the corneal epithelium have?
Approximately 5 layers
37
What is the approximate thickness of the corneal epithelium?
50 μm
38
What happens if corneal epithelium becomes keratinized?
Corneal haziness and blurred vision
39
What covers the anterior corneal epithelial surface?
Microvilli and microplicae
40
What is the function of epithelial microvilli?
Help maintain interaction with the tear film
41
What are the three layers of the tear film from outer to inner?
Lipid, aqueous, and mucin
42
Which cells secrete the mucin layer?
Goblet cells
43
Where are goblet cells most numerous?
Conjunctival fornices
44
What is the function of the mucin layer?
Promotes tear film adherence to the cornea
45
How many layers of superficial epithelial cells are present?
Two-cell layer
46
What is the morphology of superficial epithelial cells?
Flattened and dense, with fewer organelles
47
What is the morphology of wing cells?
Polyhedral cells
48
Where are wing cells located?
Above the basal cell layer
49
What is the basal germinal layer composed of?
Single layer of cuboidal to columnar cells
50
What is the approximate height of basal epithelial cells?
18 μm
51
How do corneal epithelial cells regenerate?
Basal cells multiply through mitosis and migrate superficially
52
How long does complete corneal epithelial regeneration take?
Less than one week
53
How quickly can a partial epithelial defect heal?
Approximately two days or overnight
54
What is the first acellular layer of the cornea?
Bowman's layer
55
What is another name for Bowman's layer?
Anterior limiting layer or Bowman's membrane
56
What separates the epithelium from the stroma?
Bowman's layer
57
What is the approximate thickness of Bowman's layer?
10 μm
58
What is Bowman's layer composed of?
Densely packed, randomly arranged collagen fibrils
59
What happens when Bowman's layer is destroyed?
Healing occurs through scarring
60
What is the consequence of an abrasion extending into Bowman's layer?
Corneal scarring
61
Does an epithelial abrasion confined above Bowman's layer normally scar?
No
62
What is the main function of the corneal stroma?
Provides corneal strength and shape
63
What percentage of the cornea is composed of stroma?
Approximately 90%
64
What is another name for the stroma?
Substantia propria
65
How many successive lamellae compose the stroma?
Approximately 200–300
66
What are corneal lamellae composed of?
Regularly arranged collagen fibrils embedded in extracellular matrix
67
What is the major extracellular matrix component of the stroma?
Sulfated glycosaminoglycans (GAGs)
68
What cells produce stromal collagen and extracellular matrix?
Keratocytes
69
What is the main function of keratocytes?
Maintain stromal shape and strength
70
What is the normal cellularity of the corneal stroma?
Sparsely cellular
71
What is responsible for corneal pain sensation?
Nerve fibers
72
What is the diameter of corneal collagen fibrils?
Approximately 20–60 nm
73
How does regular collagen spacing maintain corneal transparency?
Minimizes light scattering
74
What happens when stromal collagen arrangement is disrupted?
Light dispersion, corneal haze, and blurred vision
75
What is the second acellular layer of the cornea?
Descemet's membrane
76
What is another name for Descemet's membrane?
Posterior limiting layer
77
What separates the stroma from the endothelium?
Descemet's membrane
78
Which cells produce Descemet's membrane?
Corneal endothelial cells
79
How thick is Descemet's membrane during childhood?
Approximately 5 μm
80
How thick is Descemet's membrane during adulthood?
Approximately 8–10 μm
81
What is the strongest layer of the cornea?
Descemet's membrane
82
What is the clinical landmark marking the termination of Descemet's membrane?
Schwalbe's line
83
What procedure uses Schwalbe's line as a landmark?
Gonioscopy
84
What is the innermost layer of the cornea?
Endothelium
85
What is the morphology of corneal endothelial cells?
Flattened hexagonal cells
86
How many layers compose the corneal endothelium?
Single layer
87
What is the approximate thickness of the endothelium?
5–6 μm
88
What is the main function of the corneal endothelium?
Maintains corneal transparency by regulating stromal hydration
89
What happens when endothelial cell density decreases?
Reduced pump function and increased stromal hydration
90
What is the consequence of increased stromal hydration?
Corneal edema and loss of transparency
91
What are endothelial cells called when they vary in size?
Polymegathism
92
What is pleomorphism in corneal endothelium?
Variation in endothelial cell shape
93
What is the normal appearance of young corneal endothelial cells?
Uniform hexagonal cells
94
What happens to endothelial cells with aging?
Cell density decreases and cell shapes become irregular
95
What is the afferent nerve pathway of the corneal blink reflex?
CN V1
96
Where do numerous free nerve endings terminate?
Corneal epithelium
97
What dye is used to identify corneal epithelial defects?
Fluorescein
98
What color does fluorescein produce under cobalt blue illumination?
Green
99
What examination can detect corneal epithelial defects?
Slit-lamp examination
100
What syndrome results from disturbance of the epithelial basement membrane?
Recurrent corneal erosion syndrome
101
What behavior can precipitate recurrent corneal erosion?
Rubbing the eyes
102
What is the main clinical consequence of central corneal scarring?
Reduced visual acuity
103
What is the main treatment for severe corneal scarring?
Penetrating keratoplasty
104
What is microbial keratitis?
Infectious inflammation of the cornea
105
What organisms can cause microbial keratitis?
Bacteria, fungi, viruses, Acanthamoeba, Nocardia, Microsporidia, and Pythium
106
What is the main function of the cornea in vision?
Acts as the transparent optical window of the eye
107
How many corneal pathology cases occur annually according to the lecture?
Approximately 2 million
108
What percentage of blindness is attributed to trauma and infection in the lecture?
Nearly 5%
109
Why are fungal keratitis outcomes generally poorer?
Higher perforation rates and greater need for surgical intervention
110
How much more expensive is fungal keratitis treatment according to the lecture?
Approximately three times more expensive
111
What is hyperemia?
Redness and congestion of conjunctival peripheral vessels
112
What condition is commonly associated with hyperemia?
Mild conjunctivitis
113
What is ciliary injection?
Redness of ciliary vessels around the limbus
114
What does ciliary injection suggest?
Corneal disease or anterior segment inflammation
115
What are common symptoms of corneal disease?
Blurred vision, photophobia, pain, tearing, itchiness, and discharge
116
What causes photophobia in corneal disease?
Numerous corneal nerve endings
117
What causes pain in corneal disease?
Defect or injury of the corneal epithelium
118
What is a corneal ulcer?
Corneal defect involving the stroma beyond Bowman's membrane
119
What happens when a corneal ulcer violates Bowman's membrane?
Healing occurs with scarring
120
Does a corneal ulcer usually take up fluorescein?
Yes, due to the epithelial defect
121
Are corneal ulcers usually infectious?
Yes, although sterile exceptions occur
122
What is an example of a sterile corneal ulcer?
Vernal catarrh-associated ulcer
123
What characterizes a corneal ulcer clinically?
Corneal defect with stromal infiltrates and possible pus or tissue melting
124
What does a thin ulcer center with thicker surrounding margins indicate?
Corneal ulceration
125
Why are central corneal ulcers dangerous?
Risk of impending corneal perforation
126
What can corneal perforation cause?
Aqueous leakage and risk of endophthalmitis
127
What are risk factors for corneal ulcers?
Trauma, corticosteroid use, dry eyes, immunocompromise, diabetes, and contact lens wear
128
Which infection is particularly associated with contact lens use?
Pseudomonas
129
Which bacterium causes rapid corneal melting?
Pseudomonas aeruginosa
130
What is the characteristic progression of Pseudomonas keratitis?
Rapid progression and corneal melting
131
Why is Pseudomonas keratitis particularly dangerous?
Rapid ulceration and possible anterior chamber penetration
132
Which bacteria can infect an intact corneal epithelium?
Neisseria gonorrhoeae, Haemophilus, Listeria, and Corynebacterium diphtheriae
133
Which bacteria commonly cause secondary infection after epithelial injury?
Staphylococcus and Streptococcus
134
What are common causes of bacterial keratitis?
Trauma, contact lens wear, and epithelial disruption
135
What is hypopyon?
Pus accumulation in the anterior chamber
136
What does hypopyon suggest in microbial keratitis?
Severe infection or possible endophthalmitis
137
What are typical bacterial ulcer margins?
Well-defined margins with a flat profile
138
When do bacterial keratitis symptoms typically manifest?
Approximately 3–5 days after infection
139
What discharge is commonly associated with bacterial keratitis?
Purulent discharge
140
What are typical fungal ulcer margins?
Serrated, ill-defined margins with a raised profile
141
Which population is particularly at risk for fungal keratitis?
Farmers exposed to vegetative trauma
142
What is a common cause of fungal keratitis after trauma with plant material?
Fusarium
143
Which fungus commonly involves the deeper corneal stroma?
Aspergillus
144
Which fungus is associated with immunocompromised patients?
Candida
145
Which fungus is common in the southern Philippines according to the lecture?
Fusarium
146
Which fungus is common in the northern and eastern Philippines according to the lecture?
Aspergillus
147
What are risk factors for fungal keratitis?
Vegetative trauma and corticosteroid use
148
What are early signs of fungal keratitis?
Mild stromal haze and pseudodendrites
149
What is a pseudodendrite?
Branching, twig-like corneal lesion
150
Which fungal medication is mentioned for Aspergillus keratitis?
Natamycin with fluconazole
151
Which antifungal medication is mentioned for Candida keratitis?
Amphotericin B
152
Which antifungal is commonly used for Fusarium keratitis?
Natamycin
153
What is Acanthamoeba keratitis?
Protozoal corneal infection
154
Which patients commonly develop Acanthamoeba keratitis?
Contact lens wearers
155
What is a characteristic symptom of Acanthamoeba keratitis?
Severe ocular pain
156
Why is Acanthamoeba keratitis difficult to treat?
No specific treatment is available according to the lecture
157
What is the primary complaint in herpes simplex keratitis?
Pain
158
Which HSV type commonly causes ocular herpes?
HSV type 1
159
Which HSV type is sexually transmitted and rarely causes ocular disease?
HSV type 2
160
How is herpes simplex transmitted?
Through bodily fluids and saliva
161
Where does herpes simplex remain dormant after initial infection?
Nerves supplying the eye and skin
162
What can reactivate herpes simplex?
Stress, heat, trauma, hormonal changes, fever, and certain medications
163
Which patients are more likely to experience recurrent HSV infection?
Immunocompromised patients
164
What are the common symptoms of herpes simplex keratitis?
Pain, red eye, tearing, photophobia, irritation, and decreased vision
165
Is discharge typically present in epithelial herpes simplex keratitis?
No
166
What happens to corneal sensitivity in herpes simplex keratitis?
Decreased corneal sensitivity or hypoesthesia
167
What is the characteristic lesion of epithelial herpes simplex keratitis?
Dendritic ulcer
168
What are the characteristic features of HSV dendritic lesions?
Linear branching patterns with terminal bulbs
169
What diagnostic method identifies HSV dendritic ulcers?
Slit-lamp examination with fluorescein staining
170
Does epithelial HSV keratitis violate Bowman's membrane?
No
171
Does uncomplicated epithelial HSV keratitis usually scar?
No
172
How does herpes zoster ophthalmicus differ from herpes simplex keratitis?
Zoster produces dermatomal blisters; HSV produces dendritic ulcers
173
When should HSV keratitis be referred according to the lecture?
Ulcer over 3 mm, central ulcer, or one-eyed patient
174
What antiviral medications are mentioned for HSV keratitis?
Acyclovir and ganciclovir
175
How frequently are topical antiviral medications administered in the lecture?
Five times daily
176
What did the Herpetic Eye Disease Study (HEDS) investigate?
Treatments for severe ocular herpes
177
What oral acyclovir regimen is mentioned in HEDS?
400 mg four times daily
178
What was the major finding of HEDS regarding oral acyclovir?
Reduced recurrence of ocular herpes
179
When may corneal debridement be used in HSV keratitis?
To remove diseased epithelial cells
180
What is the main indication for corneal transplantation in HSV disease?
Permanent corneal scarring from severe recurrent infection
181
What causes viral keratitis in the lecture?
Adenovirus
182
What is subepithelial keratopathy?
Corneal involvement beneath an intact epithelium
183
Does subepithelial keratopathy take up fluorescein?
No
184
When may blurred vision develop after acute viral conjunctivitis?
Approximately one week later
185
What is the chief complaint in viral keratitis?
Tearing
186
Is pain typical of subepithelial viral keratopathy?
No, because the epithelium remains intact
187
What is a true anterior ocular emergency involving the cornea?
Chemical injury
188
What is the immediate first aid for chemical eye injury?
Immediate copious irrigation with water or saline
189
Which is more destructive to the eye: acid or alkali burns?
Alkali burns
190
What type of necrosis is caused by alkali burns?
Liquefactive necrosis
191
Why do alkali burns penetrate deeply?
They interact with cellular membrane lipids and cause tissue softening
192
What type of necrosis is caused by acid burns?
Coagulative necrosis
193
Why do acid burns generally penetrate less deeply?
Protein coagulation creates a barrier to further penetration
194
Which chemicals can cause alkali burns?
Lye, cement, plaster, and household cleaners
195
How long should chemical eye irrigation continue initially?
At least 30 minutes
196
What solutions can be used for chemical eye irrigation?
Saline, lactated Ringer's solution, or clean water
197
What should be done with the conjunctival fornices after chemical exposure?
Sweep with a wetted cotton applicator to remove particles
198
Should acid be used to neutralize an alkali burn?
No, never use the opposite chemical to neutralize a burn
199
What is a poor prognostic sign in ocular chemical burns?
More than 50% conjunctival or over 6 clock hours of limbal involvement
200
What are severe chemical burn findings?
Conjunctival blanching, chemosis, corneal edema, opacification, and increased IOP
201
What is hyphema?
Blood accumulation in the anterior chamber
202
What is the primary cause of traumatic hyphema?
Blunt or direct ocular trauma
203
What is the chief complaint of hyphema?
Blurred vision
204
What is the most important complication of hyphema?
Rebleeding
205
When does rebleeding commonly occur after hyphema?
3–5 days after injury
206
What percentage of hyphema cases may rebleed according to the lecture?
Approximately 30%
207
What is the grading of hyphema based on?
Amount of blood layering in the anterior chamber
208
What characterizes Grade 0 hyphema?
No layered blood; red blood cells only
209
What characterizes Grade 1 hyphema?
Blood occupying less than one-third of the anterior chamber
210
What characterizes Grade 2 hyphema?
Blood occupying one-third to one-half of the anterior chamber
211
What characterizes Grade 3 hyphema?
Blood occupying one-half to less than the entire chamber
212
What characterizes Grade 4 hyphema?
Total hyphema
213
What is a complication of uncontrolled hyphema?
Glaucoma
214
What can blood staining of the cornea cause?
Permanent corneal opacity and visual impairment
215
What is welder's keratitis?
UV-induced corneal epithelial injury
216
What causes welder's keratitis?
Unprotected exposure to welding or tanning-lamp ultraviolet radiation
217
When do symptoms of welder's keratitis typically develop?
6–12 hours after exposure
218
What are symptoms of welder's keratitis?
Pain, tearing, photophobia, and foreign-body sensation
219
What is corneal abrasion?
Superficial injury to the corneal epithelium
220
Does a simple corneal abrasion involve Bowman's membrane?
No
221
Does a simple corneal abrasion usually cause scarring?
No
222
What is the chief complaint of corneal abrasion?
Pain
223
What are typical symptoms of corneal abrasion?
Pain, photophobia, tearing, and foreign-body sensation
224
How is corneal abrasion diagnosed?
Slit-lamp examination with fluorescein staining
225
What color does an epithelial abrasion appear under cobalt blue light?
Green
226
Are topical steroids recommended for epithelial injuries?
No, they delay epithelial healing
227
What is a corneal foreign body?
An external object lodged on or within the cornea
228
What is the usual history of corneal foreign bodies?
Trauma involving an object striking the eye
229
What test detects aqueous leakage after corneal injury?
Seidel test
230
What does a positive Seidel test indicate?
Aqueous humor leaking through a corneal wound
231
What is the first step before corneal foreign body removal?
Topical anesthesia
232
What is used to remove a superficial corneal foreign body?
Wetted cotton applicator
233
What may be used to remove an embedded corneal foreign body?
Fine needle tip
234
What is dry eye disease also called?
Keratoconjunctivitis sicca
235
What is the main mechanism of aqueous-deficient dry eye?
Reduced tear production due to lacrimal gland dysfunction
236
Which systemic disease is associated with dry eye and xerostomia?
Sjögren's syndrome
237
Which autoimmune disease is associated with secondary Sjögren's syndrome?
Rheumatoid arthritis
238
Which mucocutaneous conditions can reduce mucin secretion?
Stevens-Johnson syndrome and cicatricial pemphigoid
239
What is meibomian gland dysfunction?
Abnormal function of the meibomian glands affecting the tear film lipid layer
240
What is lagophthalmos?
Inability to completely close the eyelids
241
What can cause lagophthalmos?
Facial nerve palsy
242
What is the Schirmer test used for?
Measuring tear production
243
What is a normal Schirmer test result according to the lecture?
More than 10 mm wetting in 5 minutes
244
What is tear film break-up time (BUT) used for?
Assessing tear film stability
245
What is a normal tear film break-up time?
More than 10 seconds
246
What BUT result suggests dry eye?
Less than 10 seconds
247
What does Rose Bengal stain?
Dead and devitalized ocular surface cells
248
What color does Rose Bengal produce?
Pink
249
What are the treatments for dry eye disease?
Tear substitutes, mucolytics, and punctal occlusion
250
What mucolytic concentration is mentioned for dry eye?
Acetylcysteine 5%
251
How can punctal occlusion be performed?
Temporary collagen plug or permanent cauterization
252
What is the sclera?
Dense connective tissue forming the outer coat of the eye
253
What portion of the globe is covered by the sclera?
Posterior five-sixths
254
What is the main collagen type in the sclera?
Type I collagen
255
Why does the sclera appear white?
Irregularly oriented collagen fibers
256
Are corneal and scleral collagen continuous?
Yes
257
What does the outer two-thirds of the sclera continue with at the optic disc?
Dura mater
258
What does the inner one-third of the sclera join with?
Choroidal tissue to form the lamina cribrosa
259
What passes through the lamina cribrosa?
Optic nerve fibers
260
Which muscles insert into superficial scleral collagen?
Rectus muscles
261
What is Tenon's capsule?
Anterior connective tissue covering the sclera and rectus muscles
262
What does the bulbar conjunctiva cover?
Sclera and rectus muscles
263
Where do Tenon's capsule and bulbar conjunctiva fuse?
Near the limbus
264
Is the sclera generally vascular or avascular?
Generally avascular
265
Where is the intrascleral vascular plexus located?
Posterior to the limbus
266
Where is the superficial episcleral vascular plexus located?
Beneath Tenon's capsule
267
What inflammation involves the superficial episcleral plexus?
Episcleritis
268
Where is the deeper episcleral vascular plexus located?
On the scleral surface
269
What inflammation involves the deeper vascular plexus?
Scleritis
270
What are scleral emissaria?
Apertures allowing passage of blood vessels and nerves through the sclera
271
What passes through anterior emissaria?
Anterior ciliary arteries
272
What passes through middle emissaria?
Vortex veins
273
What is the clinical significance of middle emissaria?
Potential route for extraocular extension of choroidal melanoma
274
What passes through posterior emissaria?
Short and long posterior ciliary vessels and nerves
275
What is the clinical significance of posterior emissaria?
Weakness near the lamina cribrosa
276
What are Axenfeld loops?
Loops formed by ciliary nerve branches posterior to the scleral limbus
277
Where are Axenfeld loops commonly located?
Nasal and temporal limbus
278
What are the four histological layers of the sclera from outer to inner?
Episclera, scleral stroma, lamina fusca, and endothelium
279
What is the outermost layer of the sclera?
Episclera
280
What composes the episclera?
Dense vascular connective tissue
281
What supplies blood to the episclera?
Anterior ciliary arteries
282
What is the main component of scleral stroma?
Collagen bundles, fibroblasts, proteoglycans, and glycoproteins
283
What is another name for scleral stroma?
Substantia propria
284
What is the characteristic appearance of scleral stroma?
Opaque, porcelain-white
285
What is the lamina fusca?
Pigmented inner layer of the sclera
286
What structures blend with the lamina fusca?
Suprachoroidal and supraciliary lamellae
287
What is the innermost basal lining of the sclera?
Endothelium
288
What are the three main functions of the sclera?
Maintains globe shape, resists forces, and anchors extraocular muscles
289
What is the thinnest region of the sclera?
Posterior to rectus muscle insertion
290
What is the thickness of the thinnest scleral region?
0.3 mm
291
What is the thickest region of the sclera?
Posterior pole around the optic nerve head
292
What is the thickness of the posterior sclera?
Approximately 1.0 mm
293
What is the scleral thickness at the equator?
0.4–0.5 mm
294
What is the scleral thickness anterior to muscle insertion?
0.6 mm
295
Why is scleral thickness important during surgery?
Prevents inadvertent penetration of the retina during suturing
296
What is scleral melanocytosis?
Congenital benign melanocytic hyperpigmentation of the sclera
297
What is the characteristic appearance of scleral melanocytosis?
Small black or gray-blue scleral spots
298
What causes scleral melanocytosis?
Increased melanocytes in the iris, choroid, and surrounding structures
299
What is oculodermal melanocytosis also called?
Nevus of Ota
300
What characterizes nevus of Ota?
Scleral melanocytosis with facial skin hyperpigmentation
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