Visual acuity

Visual acuity is the eye's ability to distinguish and appreciate the shape,
dimensions and details of the surrounding elements. Visual acuity is
determined using optotypes.
Visual acuity is expressed by the formula:

VA = d / D
d = the distance at which the optotype is read
D = the distance at which the letter of the respective line can be read by an
emmetropic eye.
The patient should be cooperative, understand the optotypes, be able to
communicate with the physician, and many more factors. If any of these
factors is missing, then the measurement will not represent the patient's real
visual acuity.
If the subject cannot read the optotype at a distance of 6m (the distance at
which the rays of light from an object are considered to reach parallel to the
retina), he will get close to the optotype at a distance of 1m. If in this situation
the subject reads the first line, the visual acuity is 1/50 (0,02). If the subject
cannot read even the first letter of the optotype, the visual acuity is less than
0.02 and is expressed:
-counting fingers (CF) at 30 cm, 20cm, 10 cm
-hand motion (HM)
-light perception (LP)
-no light perception

Vision testing tools

The Snellen Chart is used in most facilities for testing distance vision. They
are designed to be read at 5 metres.
 The Snellen Chart comes as a free standing cardboard chart or on a light box.
Chart should be in good order If using a light box, ALL globes must be working
to ensure standard illumination.
Each eye needs to be tested separately .Use an occluder to cover the eye that
is not being tested .If glasses are worn, the occluder goes over the top of the
glasses .If occluder is not available use the patient’s cupped hand or a patch .
Avoid pressure on the eye and be aware of patients peeking through their
fingers.
For examining the close view, where the accommodation also occurs, tables
containing texts with characters of different sizes are used.
Optotypes close read like a book, from a distance of 30-35cm, being used to
correct presbyopia.

Factors than may influence the visual acuity

Objective factors: geometric form of the test; it is necessary to use tests with a
simple and easily recognizable form;
-the contrast between the test and the background: at high contrast, visual
acuity is little influence, at low contrast, visual acuity diminishes greatly
Subjective factors
- pupil diameter: the best visual acuity is obtained when the pupil diameter is
4mm;
- the age of the subject

Binocular vision
- in humans, binocular vision is a function that is gained progressively from the
first months of life;
- for the existence of the binocular view certain conditions are required:
- sensory conditions: anatomical and dioptric integrity of the eye
- motor conditions: the anatomical-functional integrity of the oculomotor
muscles and nerves, to ensure perfect motility in all directions of the eye
The ocular refraction

The eye = adaptive optical system, 64D refractive power: 70% air-corneal
interface, 30% crystalline (it can supplement the refractive power of the eye
through an accommodation mechanism that allows a clear view of nearby
objects).
Ocular refraction = balance between 4 fundamental refractive variables:
1. the axial length of the eyeball
2. the dioptric power of the cornea
3. the dioptric power of the lens
4. the depth of the anterior chamber

Refraction: -static component

- dynamic component (accommodation)
Emmetropia = the refraction of the eye in an accommodative resting state,
when the image of the objects is formed on the retina and the 4 fundamental
refractive variables are in equilibrium.
Ametropia = the situation in which the beam of light coming from infinity is
formed at one point or more points, in front of or behind the retina. The
ametropic eye is an eye with abnormal vision without correction.

Eye refraction: - subjective methods

- objective methods
Subjective methods = are based on the response of the patient who chooses the
correction that offers the best visual acuity
Basic materials: lens box, test frame, Snellen test
The patient reads the smallest row of a Snellen test at a distance of 6m.
Evaluation of the spherical component
Corrects with progressively increasing lenses.
 It starts with a monocular test. If the subject reads the last line of a Snellen
chart, he is emmetropic or small hypermetropic. Lenses from +0.50 Dsf or +
1Dsf are added to the sample frame. If a better view is not obtained, it means
that the subject is emmetropic. If the visual acuity improves after the lens is
added, the patient is hypermetropic and the highest spherical value with the
maximum visual acuity will be prescribed.

If the patient does not read the last line, he is myopic or astigmatized, has a
high value of hypermetropia or has an organic eye disorder. Initially the + 1dsf
spherical lens is applied. If a better visual acuity is not obtained, the patient is
myopic or astigmatized. Add the concave spherical lens with which the best
view is obtained and the lowest value with which the maximum visual acuity is
obtained is prescribed.
If the patient does not read better after correction with + or - lenses, it means
that they have astigmatism and cylindrical lenses will be used.
The autorefraction test
Autorefractors measure refractive error in just seconds and automatically
determines a person's refractive errors.
After informing the patient of the need to fix the look, refraction is measured
in both eyes.

The results of the test are used to diagnose the following conditions:
- astigmatism, a refractive problem with the eye related to the shape of the
lens, which causes blurry vision
- hyperopia, which is also known as farsightedness
- myopia, which is also known as nearsightedness
- presbyopia, a condition related to aging that causes lens of the eye to have
trouble focusing
Slit lamp examination= biomicroscopy
Standard diagnostic procedure. Combines the microscope with a very bright
light source.
Gives details about the ocular surface, evidentiate discrete modifications of the
ocular surfaces that can t be apreciated with other clinical investigations.
The method completes the clinical exam.
The device has 2 components: an ilumination sistem: BEAM OF LIGHT
MICROSCOPE

We do the exam in a dark room, the subject sitting in a chair in front of the
microscope, with the chin and forehead placed in a support, looking in front.

Eyelids, eyelash,Moll and Zeiss glands, palpebral conjjunctiva, bulbar

conjunctiva
Conjunctiva: normal- smooth, hiperemia in infections , watery discharege in
viral infections, purulent discharge in bacterial infections
Sclera: normal: white , purple-red in episcleritis, scleritis, yellow in jaundice
Cornea: 45 degrees the beam of light, the 5 layers of the cornea. Drop of
flourescein, the smallest deffects on the cornea: abrasions, infections such as
keratitis, ulcers.
The depth of the anterior chamber, deseases: blood, injuries, coagulation
disfunctions, inflamatory cells in uveitis, ulcers, hipopion (collection of
leucocites and inflamatory cells as a result of bacterial toxins)
The iris
The pupil withe the pupilary reflex: dilation: simpatic effect, constriction:
parasimpatic effect
The lens: normal-transparent
Opacifiation- cataract
 Luxation, subluxation post trauma, congenital subluxation in Marfan
sd
Tonometry= the procedure performed to determinate the intraocular pressure
. It is an important test in the evaluation of patients at risk of glaucoma.
Goldmann aplanometer: iop is inferred from the force requited to flatten a
constant area of the cornea. It s considered to be the gold standard of iop test.
The exmainator uses the cobalt blue filter to view the two sei circles. The force
applied to the tonometer head ist han adjusted using a dial connected to a
tension spring, until the two semicercles are gathered together.

Non-contact tonometer: uses a air puff to aplanate the cornea

 Ocular tonometry
Goldmann tonometry

General principles: Tonometry is an objective method of measurement of the intraocular

pressure based on the necessary force of corneal flattening . Aplanation tonometry is based on the
Imbert-fick principle (P=F/A) that says for an ideal sphere, dry with thin walls, the pressure inside the
sphere(P) is equal to the force necessary for flattening it (F) divided at the surface of flattening (A).
Intraocular pressure is proportional with the pressure applied on the eyeball and with the thickness of
the walls of the globe(thickness of the cornea, which is variable). The human eye is not an ideal sphere,
the cornea is rigid and inflexible. Capillary attraction of the tear film tends to attract the tonometer on
the cornea. Corneal rigidity and capillary attraction cancel one another when the flattened surface has a
diameter of 3.06 like in Goldmann tonometry. The Goldmann tonometer is a tonometer with variable
force very precise and consists from tho prisms.

Procedure

1. Topical anesthetic and fluorescein is instilled in the conjunctival bag.

2. At the biomicroscope, the Goldmann prism is applied axial on the corneal surface.
3. Will appear two semicircles, one above and one beneath the middle horizontal line.
4. Will rotate the grading of the tonometer, until we align the interior margins of the semicircles.
5. Intraocular pressure is equal with = the grading *10

Potential errors

1 Improper model either due to excess of fluorescein( the semicircles are to thick, distance is to
small) or a small quantity of fluorescein(the semicircles are to thin, distance is to big)

2 Pressure upon the eyeball- either from the fingers of the examinator, or because of
thightening the eyelids it can result a bigger value, artificial.

3 Incorect calibrating of the tonometer can result in incorrect results. That is why is important to
verify the calibration at certain regular periods of time.

4 Corneal pathology (edema, abnormal thickness, deformation) can result in incorrect values.

5 Prolonged contact of the prism with the cornea can result in lesions that alter the result. In
case of big astigmatism, it should be measured the pressure on both meridians than the media is done.
Schiotz tonometer

Based on the principle of indentation tonometry, in which a piston with predetermined

weight is indenting the cornea. The value of indentation is measured on a scale and converted
in mmHG with a special table. The tonometer is cheap, easy to use, without the need of a
biomicroscope, but nowadays is rarely used. From the exterior it applies a constant force upon
the cornea and it measures the deformation that it produces. Schiotz tonometer has a vertical
hollow inside cylinder which at the distal extremity has a leg with the concavity in interior, and
at the proximal extremity comes in contact with an indicator that moves in front of a grading
scale. In the cylinders axe is a metal rod which will indent the central corneal area.Cylinder has
weights of 5,5 g/ 7,5 g/ 10 g/ 15 g(for higher intraocular tensions you raise the force)

Procedure

1 Pacient is in dorsal decubitus and is fixing a fixed point

2 Anesthetic is intilled

3 The tonometer is applied on the center of the cornea

4 The examiner notes the position of the indicator and the weights used

Advantages: simple procedure

Disadvantages: The calibration of the tonometer is exactly for medium ocular rigidity(k=0,0215)

A High rigidity = pressure is overestimated( hypermetropia)

B Low rigidity= pressure is underestimated(myopia)

If the rigidity is modified it can appear differences of 5mmhg

Average corneal radius is 7.8mm

A Radius bigger than the average=low apparent rigidity

B Radius smaller than the average= higher apparent rigidity. The method gives errors in case of
buftalmia or microoftalmia.

Other tonometers:

1 Perkins tonometer is an aplanation tonometer that is hold in hand, that uses a Goldmann
prism adapted at a small source of light. Is small, without the need of a biomicroscope, that is
why is used for patients that cannot move or are under anesthetic.
2. Non-contact tonometer with flush air is based on the principle of aplanation, but without
using a prisms , the central part of the cornea is flattened from a flushed air. The time necessary
for flattening the cornea is direct linked with the values of the intraocular pressure. The tool is
ea ea dd e eed ical a e he ic M l i ed f c ee i g Bigge
disadvantage is the accuracy. The flush air can scare the patient by sound and apparent force.

3 Pulsair Keeler is a noncontact tonometer to hold in the hand, which incorporates a

echa i ha ed ce e ade b he eade The ld e ake i e Offe
values comparable with The Goldmann tonometry. It is necessary a recalibration after certain
amount of time.

4 Tono-Pen is a contact tonometer, portable, works with batteries. The top of the probe
consists in a transducer that measures the applicable force. A microprocessor measures the
curve force/time generated by the transducer in time of the indentation of the cornea for
calculating the pressure. The tool correlates well the Goldmann tonometry but it overestimates
a small pressure and it underestimates a higher pressure. The biggest advantage is measuring
the pressure on an eye with corneal edema or deformation, also through contact lens.

5 Maklakoff is a tonometer with variable surface of aplanation and with constant force. Is a
dumbbell with the surface of 10mm, that can have a weight of 5/ 7,5/ 10 or 15 g. PAcient stays in
dorsal decubitus. Results are read on a scale.
 Ocular echography (ultrasound)
- Based on the property of ultrasounds to enter biological structures
- It is a method that is repeatable, painless, without costs, whithout needing a contrast substance
- Ophtalmological ultrasound probes are miniaturized and can be straight or curved
- Can be applicable on the cornea, eyelid or sclera
- Can be applicable direct on the cornea or through a fluid ( echography through immersion)

Methods:

Module A : unidimensional echography

- the transducer is applied perpendicular on the cornea
- echog am i fo med of o echo of diffe en heigh
high echo made b he an e io and po e io face of he co nea
* a isoelectric line that corresponds to the aqueous humour
* 2 high echo made b he an e io and po e io cap le of he len be een hem a
short isoelectric line that corresponds to the transparent lens
* a long isoelectric line that corresponds to the transparent vitreous
* a high echo made by the posterior wall
* descending echo columns that correspond retroocular tissue (orbital fat)

Module B : it can make a real section through the ocular globe

- Bidimensional
- From left to right : an initial echogenic area made by the cornea
A clear zone/echotransparent made by the aqueous humour
T o hin linea echo made b he cap le of he len
A clear zone, echotransparent that corresponds to the transparent lens, situated
be een he ho hin linea echo made b he cap le of he len
A large clear zone that corresponds the the transparent vitreous
A concave echogen zone made by the sclera posterior wall
Descending echo columns that correspond to orbital fat

he echo of he an e io pole can be een onl i h he imme ion me hod

Indications for ocular echography(ultrasound)

1. Echography in biometric purpose: determining the dimensions of the eyeball and its segments
And calculating the dioptric values of the artificial lens
2. Echography in diagnostic purpose:
-patology of the lens: traumatic cataract, transparency changes , abnormalities of position :
luxated, subluxated lens in vitreous
- Pathology of the vitreous: Echography is an indispensable method for investigating the vitreous
when the transparent media of the eye are affected (cornea, aqueous humour, lens)

-Vitreous hemorrhage, posterior uveitis, endophtalmitis, posterior displacement of the vitreous,

asteroid hialossis can all be investigated by echography
 Functional exploration of the lacrimal system

The lacrimal function ensures the production and elimination of tears through
the secretory and excretory system.
The secretory system ensures the production of tears by basal tear secretion
or reflex tear secretion.
Basal tear secretion is provided by the three types of glands located in the
thickness of the conjunctiva:
-mucous secreting glands- goblet cells
-accessory lacrimal glands: Krause and Wolfring
-Meibomius and Zeiss glands (lipids).
Reflex tear secretion is provided by the lacrimal gland.
Methods of examining tear secretion - quantitative tests
The Schirmer test
The test involves measuring the amount of wetting of a special filter paper,
5 mm wide and 35 mm long.
The test can be performed with or without topical anaesthesia. In theory,
when performed with an anaesthetic (Schirmer 2) basic secretion is measured
and without anaesthetic (Schirmer 1) it measures maximum basic plus reflex
secretion. In practice, however, topical anaesthesia cannot abolish all sensory
and psychological stimuli for reflex secretion. The test is performed as follows:
Excess tears are delicately dried. If topical anaesthesia is applied the excess
should be removed from the inferior fornix with filter paper. The filter paper is
folded 5 mm from one end and inserted at the junction of the middle and
outer third of the lower lid, taking care not to touch the cornea or lashes .
The patient is asked to keep the eyes gently closed. After 5 minutes the
filter paper is removed and the amount of wetting from the fold measured.
Less than 10 mm of wetting after 5 minutes without anaesthesia or less than 6
mm with anaesthesia is considered abnormal.
Results can be variable and a single Schirmer test should not be used as the
sole criterion for diagnosing dry eye, but repeatedly abnormal tests are highly
supportive.
 Schirmer Test

Qualitative tests
Tear film break-up time
It is measured as follows:
Fluorescein 2% or an impregnated fluorescein strip moistened with non-
preserved saline is instilled into the lower fornix.
The patient is asked to blink several times.
The tear film is examined at the slit lamp with a broad beam
using the cobalt blue filter. After an interval, black spots or lines appear in the
fluorescein-stained film , indicating the formation of dry areas.
The BUT is the interval between the last blink and the appearance of the first
randomly distributed dry spot. A BUT of less than 10 seconds is suspicious.

The excretory system

External examination
Punctal abnormality is the most common cause of lacrimal drainage failure.
The puncta and eyelids should be examined using a slit lamp. It is critical that
examination of the puncta is performed prior to cannulation for diagnostic
irrigation, which temporarily dilates the punctal opening and masks stenosis.
There will often be obvious tear overflow from the medial, or less commonly
the lateral, canthal region; this is more likely to indicate defective drainage
than an irritative cause.
Visible mucopurulent discharge is more likely to occur with nasolacrimal duct
obstruction than a blockage more proximally.
Punctal stenosis. This is extremely common, and has been reported as
present in up to about half of the general population; over half of patients with
evident stenosis are asymptomatic, in many cases due to insufficiency of tear
production or increased evaporation.
Ectropion, either localised to the punctal region or involving the wider lid, is
often associated with secondary stenosis .
 Punctal obstruction, usually partial, by a fold of redundant conjunctiva is
common but underdiagnosed.
In the presence of substantial lid laxity, the puncta may rarely over-ride
each other.
A pouting punctum is typical of canaliculitis.
The eyelid skin will often be moderately scaly and erythematous in chronic
epiphora.
The lacrimal sac should be palpated. Punctal reflux of mucopurulent material
on compression is indicative of a mucocele with a patent canalicular system,
but with an
obstruction either at or distal to the lower end of the lacrimal sac. In acute
dacryocystitis palpation is painful and should be avoided. Rarely, palpation of
the sac will reveal a stone or tumour.

Fluorescein disappearance test

The marginal tear strip of both eyes should be examined on the
slit lamp prior to any manipulation of the eyelids or instillation of topical
medication. The fluorescein disappearance test is performed by instilling
fluorescein 1 or 2% drops into both conjunctival fornices; normally, little or no
dye remains after 5–10 minutes. Prolonged retention is indicative of
inadequate lacrimal drainage.
Lacrimal irrigation
Lacrimal irrigation should be performed only after ascertaining
punctal patency; if absent or severely stenosed, surgical enlargement of the
punctum may be needed before canalicular and nasolacrimal duct patency can
be confirmed. It is contraindicated in acute infection.
Local anaesthetic is instilled into the conjunctival sac.
A punctum dilator is used to enlarge the punctal orifice, entering vertically
and then tilting the instrument horizontally whilst exerting lateral tension on
the lid .
A gently curved, blunt-tipped 26- or 27-gauge lacrimal cannula on a 3 ml
saline-filled syringe is inserted into the lower punctum and, whilst keeping a
gentle stretch laterally on the eyelid, advanced a few millimetres, following the
contour of the canaliculus .
A hard stop occurs if the cannula enters the lacrimal sac, coming to a stop at
the medial wall of the sac, through which can be felt the rigid lacrimal bone.
This excludes complete obstruction of the canalicular system.
Gentle saline irrigation is then attempted. If saline passes into the nose and
throat, when it will be tasted by the patient, a patent lacrimal system is
present, although there may still be stenosis; alternatively, symptoms may be
due to subtle lacrimal pump failure. Failure of saline to reach the throat is
indicative of total obstruction of the nasolacrimal duct.
In this situation, the lacrimal sac will distend slightly during irrigation and
there will be reflux, usually through both the upper and lower puncta. The
regurgitated material may be clear, mucoid or mucopurulent, depending on
the contents of the lacrimal sac.

Lacrimal irrigation
 Chemical Ocular Injuries
Chemical exposure to the eye can result in trauma ranging from mild irritation to severe damage
of the ocular surface and anterior segment with permanent vision loss. Chemical burns constitute 7.7%
18% of all ocular trauma. The majority of victims are young men. Injuries usually are caused by accidents
at work or home but also may be deliberately caused by assault. Many victims report not wearing
proper eye protection at the time of the injury. In the household setting, numerous chemicals exist in
the form of solutions in automobile batteries, pool cleaners, detergents, ammonia, bleach, and drain
cleaners. Although most injuries caused by these are mild with minimal sequelae, but in severe cases,
management can be a challenge.

ALKALI INJURIES

Alkali injuries occur more frequently and are more severe than acid injuries. Alkalis penetrate
more readily into the eye compared with acids, damaging the stroma and the endothelium, as well as
intraocular structures, such as the iris, lens, and ciliary body. Common causes of alkali injury include
ammonia (NH3), lye (NaOH), lime (CaOH]2), potassium hydroxide (KOH), and magnesium hydroxide
(Mg(OH)2). Lime, found in cement and plaster, is the most common cause of alkali injury. Damage from
lime injury is limited, however, because of the precipitation of calcium soaps that limit further
penetration. Lye and ammonia are associated with the most severe alkali injuries. Ammonia can be
detected in the anterior chamber with a rise in aqueous humor pH within seconds of exposure.
Irreversible intraocular damage has been noted to occur at aqueous pH levels of 11.5 or greater.

ACID INJURIES

Acids cause superficial damage but generally cause less severe ocular injury than alkalis, as the
immediate precipitation of epithelial proteins offers some protection by acting as a barrier to intraocular
penetration. Very strong or concentrated acids, however, can penetrate the eye just as readily as
alkaline solutions. Sulfuric (H2SO4), sulfurous (H2SO3), hydrochloric (HCl), nitric (HNO3), acetic
(CH3COOH), formic (CH2O2), and hydrofluoric (HF) acids are frequent causes of acid burns. The most
common cause is sulfuric acid, which is found in industrial cleaners and automobile batteries.
Hydrofluoric acid causes the most serious acid injuries because of its low molecular weight, which allows
easier stromal penetration. The injury may be compounded by thermal burns from heat generated by
he acid eac i n i h a e n he ea film
CLINICAL COURSE

The course of chemical injury is divided into four distinct phases: immediate, acute (0 7 days),
early reparative (7 21 days), and late reparative (after 21 days).16 Clinical findings immediately
following chemical exposure can be used to assess the severity and prognosis of the injury. The Roper-
Hall classification system (Table 4.26.1) provides a prognostic guideline based on corneal appearance
and extent of limbal ischemia. In grade I injury, there is corneal epithelial damage, no corneal opacity,
no limbal ischemia, and a good prognosis. In grade II injury, the cornea is hazy but iris details are visible.
Ischemia involves less than one third of the limbus, and the prognosis is good. In grade III injury, there is
total epithelial loss, stromal haze obscuring iris details, and ischemia of one third to one half of the
limbus, and the prognosis is guarded. In grade IV injury, the cornea is opaque with no view of the iris or
pupil, the ischemia is greater than one half of the limbus, and the prognosis is poor.

In the acute phase during the first week, grade I injuries heal, whereas in grade II injuries,
corneal clarity is recovered slowly. Grade III and IV injuries have little or no re-epithelization, with no
collagenolysis or vascularization. IOP may be elevated as a result of inflammation and mechanical
distortion of the trabecular meshwork or decreased because of ciliary body damage. During the early
reparative phase, re-epithelization is completed in grade II injury, with clearing of opacification. In more
severe cases, delayed or arrested re-epithelization may occur. Keratocyte proliferation occurs with
production of collagen and collagenase, resulting in progressive thinning and potential for perforation.

In the late reparative phase, re-epithelization patterns divide injured eyes into two groups. In
the first group, epithelization is complete or is nearly complete, with sparing of limbal stem cells.
Corneal anesthesia, goblet cell and mucin abnormalities, and irregular epithelial basement membrane
regeneration may persist. In the second group, limbal stem cell damage is present, resulting in corneal
re-epithelization by conjunctival epithelium. This group has the worst prognosis with severe ocular
surface damage characterized by vascularization and scarring, goblet cell and mucin deficiency, and
recurrent or persistent erosions. Ocular surface abnormalities may be exacerbated by symblepharon
formation, cicatricial entropion, and trichiasis. A fibrovascular pannus results if ulceration does not
occur, compromising visual rehabilitation.
TABLE 4.26.1 Roper-Hall Classification

Grade Prognosis Conjunctival Corneal Involvement

Involvement

I Good None Epithelial damage

II Good Less than 33% limbal Stromal haze present but iris details
ischemia visible

III Guarded 33% 50% limbal Total epithelial loss, stromal haze
ischemia obscures iris details

IV Poor Greater than 50% Cornea opaque, iris and pupil obscured
limbal ischemia

From Roper-Hall MJ. Thermal and chemical burns. Trans Ophthalmol Soc UK 1965;85:631 53.

THERAPY

Immediate Phase
Because the area and duration of contact determines the extent of subsequent injury and
prognosis, immediate copious irrigation upon exposure is of paramount importance. Irrigation should be
continued for at least 15 minutes with at least 1 L of irrigant, until the pH of the ocular surface reaches
neutrality. Currently available solutions include normal saline, borate-buffered saline, balanced salt
solution, phosphate-b ffe ed aline lac a ed Ringe and am h e ic l i ns that aim to chelate
acids and alkalis and create a reverse osmotic gradient to draw chemicals out of the cornea. Some
authors discourage the use of phosphate-buffered saline, which may lead to precipitation of calcium in
the corneal stroma. Borate-buffered saline and amphoteric solutions were found to be most effective in
reducing aqueous humor pH after an alkali burn. Normal saline and tap water were found to be
in e media el effec i e and h ha e b ffe ed aline and lac a ed Ringe e e f nd have the
least effective buffering capacity. If access to commercial irrigating solutions is not immediately
available, tap water should be used despite the fact that it is hypo-osmolar and may contribute to
corneal edema. If an acid burn is suspected, a base should never be used for irrigation in an effort to
neutralize the acid. A retained reservoir of chemical in the fornices should be suspected if neutrality
cannot be achieved, especially with exposure to lime, which can be embedded in the fornices and the
upper tarsal conjunctiva. Eversion of the lids and removal of particulate matter should be performed; a
cotton-tipped applicator soaked in ethylenediaminetetraacetic acid 1% may help with the removal of
stubborn lime particles. Necrotic corneal and conjunctival tissues should be debrided to promote re-
epithelization because this debris provides a stimulus for continued inflammation with recruitment of
neutrophils and mucous membrane pemphigoid production.

Acute and Reparative Phases

After irrigation, all efforts should be made to promote epithelial wound healing, prevent
infection, reduce inflammation, minimize ulceration, and control intraocular pressure. Topical antibiotics
should be used if there is any corneal or conjunctival epithelial defect. Topical and systemic ocular
hypotensive medications may be needed. Better outcomes can be expected with prompt re-
epithelization, while delayed or absent re-epithelization may require surgical intervention. Bandage
contact lenses or amniotic membrane transplantation may be used to promote epithelial healing.35,36
Intensive topical corticosteroid therapy every 1 2 hours in the first 1 2 weeks decreases the
inflammatory response that can delay epithelial migration, and thus helps enhance re-epithelization in
the early phases of injury. Corticosteroid use in the first 10 days of injury has no adverse effect on
outcome with little risk of sterile ulceration. Prolonged use of corticosteroids, however, can be
deleterious since corticosteroids can blunt stromal wound repair by decreasing keratocyte migration
and collagen synthesis. Beyond 2 weeks at the peak of the early reparative phase, suppression of
keratocyte collagen production by continued use of corticosteroids may offset the benefits of
inflammatory suppression and lead to stromal ulceration. Corticosteroid use should, therefore, be
stressed in the first 2 weeks with subsequent taper as dictated by clinical examination.
Medroxyprogesterone 1% is a synthetic progestogenic corticosteroid that has weaker anti-inflammatory
activity compared with corticosteroids. Medroxyprogesterone inhibits collagenase, but unlike
corticosteroids, it minimally suppresses stromal wound repair. As such, medroxyprogesterone can be
substituted for corticosteroid after 10 14 days if worsening ulceration is of concern.

Surgical Therapy
Surgical interventions that may help stabilize the ocular surface after severe chemical injury
include tarsorrhaphy to promote epithelial healing, superficial keratectomy to remove localized corneal
pannus from focal limbal stem cell deficiency, limbal stem cell transplantation for diffuse limbal stem
cell deficiency, and amniotic membrane transplantation. Tenoplasty and amniotic membrane
transplantation are additional strategies to aid epithelial healing, Tenoplasty attempts to re-establish
vascularity to ischemic areas of the limbus and to promote re-epithelization. In this procedure, all
nec ic c nj nc i al and e i cle al i e a e e ci ed Ten n ca le i bl n l di ec ed and he
resultant flap with its preserved blood supply is advanced to the limbus
 Ophthalmoscopy

Ophthalmoscopy is an objective method that allows examination

of the retina, optic nerve head and transparent medias of the eye.
Ophthalmoscopy is performed with a device named
ophthalmoscope.

Direct ophthalmoscopy

Direct ophthalmoscope

Procedure of direct ophthalmoscopy:

-the routine fundus examination in ophthalmologic patients is
generally done through the dilated pupil ( mydriatic drops);
-patient it`s set in a semi dark room and instruct to look at a
distant target;
 - while examining the right eye, the ophthalmoscope it is hold
with the right hand, and examining with the right eye on the right
side of the patient;
-examine for the red reflex at arm`s length:
-normal-red glow from choroid;
-look for opacities or loose of reflex;
-the examiner moves as close as to the patient to examine
anterior segment;
-than, crystaline lens, vitreous and the optic nerve head can be
observed, followed by the optic disc ; The optic disc is examined for
colour, contour (margin, shape, elevation), cup-disc ratio;
-each vessel it`s followed to the periphery;
-after quadrant by quadrant scan of fundus, the macula is
examined;

Clinical importance:
-dark or semi-dark spot over the reflex : opacity;
-if no reflex: totally opaque lens (cataract);
- vitreous haemorrhage ;
 -total retinal detachment;
- crescentic ring in pupillary area: subluxated lens;
 Ocular Trauma
The eyeball is covered by the eyelids in the anterior part, which because of their structure they
assure a partial protection for eventual trauma. Considering their nature, ocular trauma can be
classified:

-contusions

-wounds cut or stung with or without retension of foreign bodies

-chemical or physical burns

Ocular contusions
Appear after a contusive trauma( fist, tennis ball/football ball, stone, champagne cork, snowball
etc), followed by major and brutal deformities of the eyeball. Firstly, the antero-posterior axis is
shortened and an enlarging of the diameter or transversally. Secondly, the contusive force faces the
resistance of the posterior sclera comes backward pushing masses of the vitreous and the
iridocrystalline diaphragm . From here comes the possibility of lesions at all levels(the recoil of the
iridocornean angle, iridodialyssis, posterior subluxation or luxation of the lens, retinal detachment,
contusive syndrome of the posterior pole with retinal edema and coroidal ruptures. The moment the
trauma is produced , a lively pain accompanied by a partial or total loss of vision appears. Exploring the
lesions is done layer by layer from the anterior to the posterior.

Ocular contusions can be:

-direct, when the traumatic factor acts directly on the eyeball

-indirect, when the traumatic factor acts on the neighbouring regions

The eyelids can present abrations or bruises, big hematoma, and deep wounds crushed or cut,
more frequently when the eyelids tissues are caught between the traumatic agent and the hard orbital
margin.The treatment is surgical associated with administrating antibiotics and ATPA.

Conjunctiva: subconjunctival hemorrhages more or less visible.If they are accentuated we have
to make sure they don t hide a more important lession of the deeper layers

The cornea can present epithelial erosions or small superficial wounds, because of the direct
contact with the causing agent. The treatment consists in drops with antibiotics, ephitelisants and
therapeutic contact lenses. Sometimes the cornea can suffer an edematous and cellular infiltration ,
accompanied by folds of the Descemet membrane, a deep traumatic keratitis situated in the central and
deep part of the cornea. Sometimes it produces an hematic impregnation of the cornea(hematocornea)
coloured brown-red which can be followed by a secondary glaucoma as a complication.
 The anterior chamber can be normal or can present alterations of depth and content. Is
deeper when a luxation or subluxation of the lens towards the vitreous is produced or when ocular
hipotony is installed. It is small when an ocular hypertension occurred. In the anterior chamber can be
found a smaller or larger amount of blood which is deposited in the declining part and which results
from iridocilliary ruptures. In case of massive hemorrhages, drainage is needed in order to prevent
hematocornea.

The iris can present radiar ruptures of the pupilary margins, or the desinsertion of the base of
the iris(iridodialissis). The pupil is in mydrissis, irregular and rigid.Even without a rupture the iris is the
main spot of an inflammatory process(iritis/iridocyclitis posttraumatic).

The lens can suffer dislocations (subluxation/luxation) or opacities( traumatic cataract). Both
subluxations or luxations can be a trigger for 2 major complications: secondary glaucoma and
opacifiation of the lens. Traumatic cataract that results from contusions of the eyeball is a result of
either a tear from the reaction of the posterior capsule either by only the contusion of the fibers from
the whole capsule. The cataract is being visible in days-weeks time.

The retina can present hemorrhages, edema or tears/retinal detachment

-Hemorrhages are situated in different sectors and can affect all the layers of the retina, their
severity is made by the intensity or location.

-Edema is located especially at the posterior pole. A particular form of edema is Berlin edema
which appears at the retinal examination coloured white-grey , proeminent, unclear margins, occupying
the whole posterior pole in the center which the macula contrasts by the reddish colour.

-Retinal tears: macular hole( red, clear margins, central scotoma) or/and retinal detachment (as
a result of retinal tear)

Coroida: can occur hemmohrages or coroidal tears. Sometimes coroidal detachments occur
which consists of brown formation well delimited.

Contusions can be accompanied by alterations of the intraocular pressure(hypo or

Hypertension) and changes of the refraction(Hypermetropy because of the damaged cilliary muscle or
Myopia because of the spasm of the cilliary muscle)

Scleral tears can occur in 2 places of minimum ressistance: at the ecuator(where the sclera is
thinner) or more frequently near the sclero-corneal limbus(where the penetrating holes of the anterior
cilliary arteries reduce the ressistance)
Perforating injuries
Ocular penetrating and perforating injuries can result in severe vision loss or loss of the eye.
Penetrating injuries by definition penetrate into the eye but not through and through--there is no exit
wound. Perforating injuries have both entrance and exit wounds. Most individuals sustaining eye
injuries are male with an estimated relative risk of 5.5 times greater than women. The etiology is
multiple and includes: any sharp or high velocity object, rocks, sticks, knives, scissors, screwdrivers and
nails.Can be linear, irregular or just a spot. Sometimes barely visible, and sometimes they cover all the
cornea heading to the limbus and sclera. Small wounds heal quickly, the bigger ones frequently require
surgery also because in the wound tissues are protruding. Ocular symptoms:

-shallow or flat anterior chamber

-hyphema

- iris deformities
-lens disruption, or posterior segment findings such as vitreous hemorrhage, retinal tears,
retinal hemorrhage are concerning when seen in a patient with suspected trauma.

Corneal traumatic perforation comes with pain , photofobia, perikeratic congestion, loss of
vision and sometimes the appearance of a wave of warm liquid pouring down the cheek(aqueous
humour). Traumatic injuries of the cornea can have major complications: infections, the wound margins
become infiltrated and the cornea has edema.If the infection is not treated properly in 2-3 days
endophtalmitis can occur or fibrinoplastic exudative uveitis which can finally conclude to sympathetic
ophtalmy.

In order to maintain a higher functionality of the eye and to prevent complications ,surgical
treatment must be applied as soon as possible. Stinging wounds heal spontaneously. If the iris is caught
in the wound and no more than 2 hours past from the accident it can be repositioned, if not it will be
resected also with the adherences caught in wounds margins, afterwards corneal suture can be done. If
the wounds margins are crushed or irregular either conjunctival covering or keratoplasty can be
performed .After the surgery instillation of midriatics, antibiotics, antiinflamatory drops is the required
treatment also with a sterile oclusive patch that covers the eye.The healing process of the corneal
lesions leave a opaque scar-leukoma and if the iris in caught in the scar adherent leukoma.

Scleral injuries occur in the same conditions as corneal. The treatment is suturing after the
resections of the herniated membranes. Extremely dangerous are perforating injuries of the perilimbic
part of the sclera. Possible complications are sympathetic ophtalmia or uveitis. Conjunctival injuries are
sutured separately .Absolute indication of enucleation of the eyeball are crushed big injuries with
irregular margins , with impossible healing of the wound, or intraocular severe damages with loss of
vision.