49  T_h e eye and orbit

Acute angle closure
Acute angle closure
This usually occurs in older, often hypermetropic, patients. The prevalence is much higher in some Asian populations. The cornea becomes hazy , the pupil oval, dilated and non-reacting, the vision poor and the eye feels hard. In severe cases pain may be accompanied by vomiting and the condition can be mistaken for an acute abdominal problem. Tonometry (intraocular measurement) and examination of  the iridocorneal angle by gonioscopy (using a prism placed on the cornea) is diagnostic. Urgent treatment to reduce the pressure with pilocarpine eyedrops, oral acetazolamide and, if  refractory , mannitol should be started, followed by yttrium aluminium garnet (YAG) laser iridotomy , laser iridoplasty , anterior chamber paracentesis or surgical iridectomy . The condition is usually bilateral and the second eye usually needs a prophylactic iridotomy at the same time. Except for a simple conjunctivitis and subconjunctival haemorrhage, which are self-limiting, the management of  an acute red eye requires expert treatment and a specialist opinion should be sought. A painful eye with a cranial nerve III palsy (ptosis, dilated pupil, globe down and out) often signifies an intracranial aneurysm and should be investigated immediately . This may occur in one or both eyes, and the visual loss may be transient or permanent. Possible causes are: /uni25CF Acute : /uni25CF obstruction of  the central retinal artery ( Figure 49.32 ); /uni25CF obstruction of  the central retinal vein ( Figure 49.33 ); - /uni25CF ischaemic optic neuropathy; /uni25CF migraine and other vascular causes; - /uni25CF vitreous and retinal haemorrhages; /uni25CF retinal detachment ( Figure 49.34 ); - /uni25CF macular hole, cyst or haemorrhage; /uni25CF cystoid macular oedema, often after surgery; /uni25CF hysterical blindness. /uni25CF Chronic : /uni25CF cataract; /uni25CF glaucoma; /uni25CF macular degeneration. /uni25CF diabetic retinopathy .
Figure 49.31
Episcleritis.
Figure 49.32
Retinal artery occlusion.
Figure 49.33
Central retinal vein occlusion.
Specialist help should be sought in any case of  loss of vision. The possibility of  temporal arteritis should always be considered in the di ff erential diagnosis of sudden visual loss, as prompt treatment of  this condition is extremely important. Elderly patients with sudden visual loss should be specifically asked for symptoms of  scalp tenderness and jaw claudication and temporal arteries should be palpated for pulsation and ten derness. The erythrocyte sedimentation rate and C-reactive protein should be measured immediately if temporal arteritis is suspected, and the carotid system should be examined for bruits and other signs of  arteriosclerosis in cases of  ischaemic optic neuropath y and central retinal artery occlusion. Glau coma, hypertension, hyperviscosity syndromes and diabetes should be looked for in cases of  central vein thrombosis.
Figure 49.34
B-scan of a retinal detachment.
Acute angle closure
This usually occurs in older, often hypermetropic, patients. The prevalence is much higher in some Asian populations. The cornea becomes hazy , the pupil oval, dilated and non-reacting, the vision poor and the eye feels hard. In severe cases pain may be accompanied by vomiting and the condition can be mistaken for an acute abdominal problem. Tonometry (intraocular measurement) and examination of  the iridocorneal angle by gonioscopy (using a prism placed on the cornea) is diagnostic. Urgent treatment to reduce the pressure with pilocarpine eyedrops, oral acetazolamide and, if  refractory , mannitol should be started, followed by yttrium aluminium garnet (YAG) laser iridotomy , laser iridoplasty , anterior chamber paracentesis or surgical iridectomy . The condition is usually bilateral and the second eye usually needs a prophylactic iridotomy at the same time. Except for a simple conjunctivitis and subconjunctival haemorrhage, which are self-limiting, the management of  an acute red eye requires expert treatment and a specialist opinion should be sought. A painful eye with a cranial nerve III palsy (ptosis, dilated pupil, globe down and out) often signifies an intracranial aneurysm and should be investigated immediately . This may occur in one or both eyes, and the visual loss may be transient or permanent. Possible causes are: /uni25CF Acute : /uni25CF obstruction of  the central retinal artery ( Figure 49.32 ); /uni25CF obstruction of  the central retinal vein ( Figure 49.33 ); - /uni25CF ischaemic optic neuropathy; /uni25CF migraine and other vascular causes; - /uni25CF vitreous and retinal haemorrhages; /uni25CF retinal detachment ( Figure 49.34 ); - /uni25CF macular hole, cyst or haemorrhage; /uni25CF cystoid macular oedema, often after surgery; /uni25CF hysterical blindness. /uni25CF Chronic : /uni25CF cataract; /uni25CF glaucoma; /uni25CF macular degeneration. /uni25CF diabetic retinopathy .
Figure 49.31
Episcleritis.
Figure 49.32
Retinal artery occlusion.
Figure 49.33
Central retinal vein occlusion.
Specialist help should be sought in any case of  loss of vision. The possibility of  temporal arteritis should always be considered in the di ff erential diagnosis of sudden visual loss, as prompt treatment of  this condition is extremely important. Elderly patients with sudden visual loss should be specifically asked for symptoms of  scalp tenderness and jaw claudication and temporal arteries should be palpated for pulsation and ten derness. The erythrocyte sedimentation rate and C-reactive protein should be measured immediately if temporal arteritis is suspected, and the carotid system should be examined for bruits and other signs of  arteriosclerosis in cases of  ischaemic optic neuropath y and central retinal artery occlusion. Glau coma, hypertension, hyperviscosity syndromes and diabetes should be looked for in cases of  central vein thrombosis.
Figure 49.34
B-scan of a retinal detachment.
Acute angle closure
This usually occurs in older, often hypermetropic, patients. The prevalence is much higher in some Asian populations. The cornea becomes hazy , the pupil oval, dilated and non-reacting, the vision poor and the eye feels hard. In severe cases pain may be accompanied by vomiting and the condition can be mistaken for an acute abdominal problem. Tonometry (intraocular measurement) and examination of  the iridocorneal angle by gonioscopy (using a prism placed on the cornea) is diagnostic. Urgent treatment to reduce the pressure with pilocarpine eyedrops, oral acetazolamide and, if  refractory , mannitol should be started, followed by yttrium aluminium garnet (YAG) laser iridotomy , laser iridoplasty , anterior chamber paracentesis or surgical iridectomy . The condition is usually bilateral and the second eye usually needs a prophylactic iridotomy at the same time. Except for a simple conjunctivitis and subconjunctival haemorrhage, which are self-limiting, the management of  an acute red eye requires expert treatment and a specialist opinion should be sought. A painful eye with a cranial nerve III palsy (ptosis, dilated pupil, globe down and out) often signifies an intracranial aneurysm and should be investigated immediately . This may occur in one or both eyes, and the visual loss may be transient or permanent. Possible causes are: /uni25CF Acute : /uni25CF obstruction of  the central retinal artery ( Figure 49.32 ); /uni25CF obstruction of  the central retinal vein ( Figure 49.33 ); - /uni25CF ischaemic optic neuropathy; /uni25CF migraine and other vascular causes; - /uni25CF vitreous and retinal haemorrhages; /uni25CF retinal detachment ( Figure 49.34 ); - /uni25CF macular hole, cyst or haemorrhage; /uni25CF cystoid macular oedema, often after surgery; /uni25CF hysterical blindness. /uni25CF Chronic : /uni25CF cataract; /uni25CF glaucoma; /uni25CF macular degeneration. /uni25CF diabetic retinopathy .
Figure 49.31
Episcleritis.
Figure 49.32
Retinal artery occlusion.
Figure 49.33
Central retinal vein occlusion.
Specialist help should be sought in any case of  loss of vision. The possibility of  temporal arteritis should always be considered in the di ff erential diagnosis of sudden visual loss, as prompt treatment of  this condition is extremely important. Elderly patients with sudden visual loss should be specifically asked for symptoms of  scalp tenderness and jaw claudication and temporal arteries should be palpated for pulsation and ten derness. The erythrocyte sedimentation rate and C-reactive protein should be measured immediately if temporal arteritis is suspected, and the carotid system should be examined for bruits and other signs of  arteriosclerosis in cases of  ischaemic optic neuropath y and central retinal artery occlusion. Glau coma, hypertension, hyperviscosity syndromes and diabetes should be looked for in cases of  central vein thrombosis.
Figure 49.34
B-scan of a retinal detachment.

Adults
Adults
Malignant melanoma is the most common primary malignant tumour of  the eye and originates in the pigmented cells of  the choroid ( Figure 49.14 ), ciliary body or iris. It can present with a reduction in vision, a vitreous haemorrhage or by the chance finding of  an elevated pigmented lesion in the eye. Tumour growth is variable but, as a general rule, the more posterior the lesion, the more rapidly progressive it is likely to be. Spread may be delayed for many years; however, the liver is frequently involved, hence the advice ‘beware of  the patient with a glass eye and an enlarged liver’. Treatment options vary by size and location of  the tumour but include laser photocoagula - tion, radioactive plaque, radiotherapy/proton beam therapy , enucleation and, in selected cases, local excision. Diagnosis is made by direct observation and/or ultrasonography , which shows a solid tumour, often with low inter nal reflectivity on ultrasound ( Figure 49.15 ).
Figure 49.14
Choroidal melanoma.
Figure 49.15
B-scan showing choroidal melanoma (courtesy of Dr
Marie Reston).
Adults
Malignant melanoma is the most common primary malignant tumour of  the eye and originates in the pigmented cells of  the choroid ( Figure 49.14 ), ciliary body or iris. It can present with a reduction in vision, a vitreous haemorrhage or by the chance finding of  an elevated pigmented lesion in the eye. Tumour growth is variable but, as a general rule, the more posterior the lesion, the more rapidly progressive it is likely to be. Spread may be delayed for many years; however, the liver is frequently involved, hence the advice ‘beware of  the patient with a glass eye and an enlarged liver’. Treatment options vary by size and location of  the tumour but include laser photocoagula - tion, radioactive plaque, radiotherapy/proton beam therapy , enucleation and, in selected cases, local excision. Diagnosis is made by direct observation and/or ultrasonography , which shows a solid tumour, often with low inter nal reflectivity on ultrasound ( Figure 49.15 ).
Figure 49.14
Choroidal melanoma.
Figure 49.15
B-scan showing choroidal melanoma (courtesy of Dr
Marie Reston).
Adults
Malignant melanoma is the most common primary malignant tumour of  the eye and originates in the pigmented cells of  the choroid ( Figure 49.14 ), ciliary body or iris. It can present with a reduction in vision, a vitreous haemorrhage or by the chance finding of  an elevated pigmented lesion in the eye. Tumour growth is variable but, as a general rule, the more posterior the lesion, the more rapidly progressive it is likely to be. Spread may be delayed for many years; however, the liver is frequently involved, hence the advice ‘beware of  the patient with a glass eye and an enlarged liver’. Treatment options vary by size and location of  the tumour but include laser photocoagula - tion, radioactive plaque, radiotherapy/proton beam therapy , enucleation and, in selected cases, local excision. Diagnosis is made by direct observation and/or ultrasonography , which shows a solid tumour, often with low inter nal reflectivity on ultrasound ( Figure 49.15 ).
Figure 49.14
Choroidal melanoma.
Figure 49.15
B-scan showing choroidal melanoma (courtesy of Dr
Marie Reston).

Blunt injuries to the eye and orbit
Blunt injuries to the eye and orbit
The floor of  the orbit is its weakest wall and in blunt trauma, such as a blow from a fist, it is often fractured without fractures of  the other walls. This is called a blow-out fracture. Clinical - signs are enophthalmos, bruising around the orbit, maxillary hypoaesthesia and limitation of  upward gaze owing to entrap - ment of  the inferior rectus muscle leading to vertical diplopia. This occurs when the extraocular muscles or orbital septa become trapped in the fracture and can be identified as a soft-tissue mass in the antrum on a radiograph ( Figure 49.17 although CT scans or tomograms may be necessary . Surgical repair of  the orbital floor with freeing of  the trapped contents may be necessary if  troublesome diplopia persists or enophthalmos is marked. A child with an orbital floor fracture requires urgent assessment, particularly if  upgaze is restricted, as trapping of  the inferior rectus muscle may cause ischaemia and require urgent surgery . If  an orbital haemorrhage is too extensive to examine the eye, it may be necessary to examine the eye under anaesthesia because there may be a hidden perforation of the globe. Injuries to the lids and lid margins must be repaired; if  the lacrimal canaliculi are damaged, they should be repaired if  possible, especially the lower canaliculus, as 75% of  tear drainage goes through it. Blunt injuries can also cause damage to the optic nerve, which can result in blindness and a total a ff erent nerve defect ( Figures 49.18 and 49.19 ).
Figure 49.17
Radiograph showing a blow-out fracture of the orbit
(left) with soft tissue in the antrum (arrow) (courtesy of Dr Glyn Lloyd).
Figure 49.18
Injury from a ski pole into the right brow. Vision reduced
to ‘no perception of light’ (courtesy of J Beare, FRCS).
Blunt injuries to the eye and orbit
The floor of  the orbit is its weakest wall and in blunt trauma, such as a blow from a fist, it is often fractured without fractures of  the other walls. This is called a blow-out fracture. Clinical - signs are enophthalmos, bruising around the orbit, maxillary hypoaesthesia and limitation of  upward gaze owing to entrap - ment of  the inferior rectus muscle leading to vertical diplopia. This occurs when the extraocular muscles or orbital septa become trapped in the fracture and can be identified as a soft-tissue mass in the antrum on a radiograph ( Figure 49.17 although CT scans or tomograms may be necessary . Surgical repair of  the orbital floor with freeing of  the trapped contents may be necessary if  troublesome diplopia persists or enophthalmos is marked. A child with an orbital floor fracture requires urgent assessment, particularly if  upgaze is restricted, as trapping of  the inferior rectus muscle may cause ischaemia and require urgent surgery . If  an orbital haemorrhage is too extensive to examine the eye, it may be necessary to examine the eye under anaesthesia because there may be a hidden perforation of the globe. Injuries to the lids and lid margins must be repaired; if  the lacrimal canaliculi are damaged, they should be repaired if  possible, especially the lower canaliculus, as 75% of  tear drainage goes through it. Blunt injuries can also cause damage to the optic nerve, which can result in blindness and a total a ff erent nerve defect ( Figures 49.18 and 49.19 ).
Figure 49.17
Radiograph showing a blow-out fracture of the orbit
(left) with soft tissue in the antrum (arrow) (courtesy of Dr Glyn Lloyd).
Figure 49.18
Injury from a ski pole into the right brow. Vision reduced
to ‘no perception of light’ (courtesy of J Beare, FRCS).
Blunt injuries to the eye and orbit
The floor of  the orbit is its weakest wall and in blunt trauma, such as a blow from a fist, it is often fractured without fractures of  the other walls. This is called a blow-out fracture. Clinical - signs are enophthalmos, bruising around the orbit, maxillary hypoaesthesia and limitation of  upward gaze owing to entrap - ment of  the inferior rectus muscle leading to vertical diplopia. This occurs when the extraocular muscles or orbital septa become trapped in the fracture and can be identified as a soft-tissue mass in the antrum on a radiograph ( Figure 49.17 although CT scans or tomograms may be necessary . Surgical repair of  the orbital floor with freeing of  the trapped contents may be necessary if  troublesome diplopia persists or enophthalmos is marked. A child with an orbital floor fracture requires urgent assessment, particularly if  upgaze is restricted, as trapping of  the inferior rectus muscle may cause ischaemia and require urgent surgery . If  an orbital haemorrhage is too extensive to examine the eye, it may be necessary to examine the eye under anaesthesia because there may be a hidden perforation of the globe. Injuries to the lids and lid margins must be repaired; if  the lacrimal canaliculi are damaged, they should be repaired if  possible, especially the lower canaliculus, as 75% of  tear drainage goes through it. Blunt injuries can also cause damage to the optic nerve, which can result in blindness and a total a ff erent nerve defect ( Figures 49.18 and 49.19 ).
Figure 49.17
Radiograph showing a blow-out fracture of the orbit
(left) with soft tissue in the antrum (arrow) (courtesy of Dr Glyn Lloyd).
Figure 49.18
Injury from a ski pole into the right brow. Vision reduced
to ‘no perception of light’ (courtesy of J Beare, FRCS).

Blunt ocular injuries
Blunt ocular injuries
Blunt injuries to the eye can give rise to several problems, which include the following: /uni25CF Iritis . Inflammation; treated with topical steroids. /uni25CF Hyphaema (blood in the anterior chamber) ( Figure 49.20 ). Rest and sedation, particularly in children, ), are advised because the main danger in this condition is secondary bleeding, resulting in an acute rise in intraocular pressure and blood staining of  the cornea. The use of antifibrinolytic agents ( ε -aminocaproic acid) has been advocated; if the pressure rises, surgery to wash out the blood may be necessary . /uni25CF Subluxation of  the lens . This is suspected if  the iris, or part of  the iris, ‘wobbles’ on movement (iridodonesis). /uni25CF Secondary glaucoma . This is often associated with recession of  the iridocorneal drainage angle. /uni25CF Retinal and macular haemorrhages and chor- oidal tears ( Figure 49.21 ). /uni25CF Retinal dialysis . This may lead to a retinal detachment and permanent damage to vision ( Figure 49.22 ).
Figure 49.19
Scan of orbit from
Figure 49.18
showing a massive
swelling of the medial rectus (courtesy of J Beare, FRCS).
Figure 49.20
Hyphaema. Blood in the vitreous chamber after a con
cussional injury.
Blunt ocular injuries
Blunt injuries to the eye can give rise to several problems, which include the following: /uni25CF Iritis . Inflammation; treated with topical steroids. /uni25CF Hyphaema (blood in the anterior chamber) ( Figure 49.20 ). Rest and sedation, particularly in children, ), are advised because the main danger in this condition is secondary bleeding, resulting in an acute rise in intraocular pressure and blood staining of  the cornea. The use of antifibrinolytic agents ( ε -aminocaproic acid) has been advocated; if the pressure rises, surgery to wash out the blood may be necessary . /uni25CF Subluxation of  the lens . This is suspected if  the iris, or part of  the iris, ‘wobbles’ on movement (iridodonesis). /uni25CF Secondary glaucoma . This is often associated with recession of  the iridocorneal drainage angle. /uni25CF Retinal and macular haemorrhages and chor- oidal tears ( Figure 49.21 ). /uni25CF Retinal dialysis . This may lead to a retinal detachment and permanent damage to vision ( Figure 49.22 ).
Figure 49.19
Scan of orbit from
Figure 49.18
showing a massive
swelling of the medial rectus (courtesy of J Beare, FRCS).
Figure 49.20
Hyphaema. Blood in the vitreous chamber after a con
cussional injury.
Blunt ocular injuries
Blunt injuries to the eye can give rise to several problems, which include the following: /uni25CF Iritis . Inflammation; treated with topical steroids. /uni25CF Hyphaema (blood in the anterior chamber) ( Figure 49.20 ). Rest and sedation, particularly in children, ), are advised because the main danger in this condition is secondary bleeding, resulting in an acute rise in intraocular pressure and blood staining of  the cornea. The use of antifibrinolytic agents ( ε -aminocaproic acid) has been advocated; if the pressure rises, surgery to wash out the blood may be necessary . /uni25CF Subluxation of  the lens . This is suspected if  the iris, or part of  the iris, ‘wobbles’ on movement (iridodonesis). /uni25CF Secondary glaucoma . This is often associated with recession of  the iridocorneal drainage angle. /uni25CF Retinal and macular haemorrhages and chor- oidal tears ( Figure 49.21 ). /uni25CF Retinal dialysis . This may lead to a retinal detachment and permanent damage to vision ( Figure 49.22 ).
Figure 49.19
Scan of orbit from
Figure 49.18
showing a massive
swelling of the medial rectus (courtesy of J Beare, FRCS).
Figure 49.20
Hyphaema. Blood in the vitreous chamber after a con
cussional injury.

Burns
Burns
Radiation burns Corneal injury may occur after exposure to ultraviolet radia - tion, for example after arc welding or excessive sunlight (snow blindness) and sun lamps. Such burns cause intense gritty burning pain and photophobia as a result of  keratitis (corneal inflammation), which starts some hours after exposur e. Mydri - atic and local steroids with antibiotic drops ease the condition, and healing usually occurs after 24 hours. Thermal burns If  these involve the full thickness of  the lids, corneal scarring may occur from exposure and immediate corneal protection is necessary . A splash of  molten metal may cause marked local necrosis and may lead to permanent corneal scarring. Treatment is to remove any debris by irrigation and to instil local atropine, antibiotics and steroids to prevent superadded infection and scarring. Lid reconstruction may be necessary . Chemical burns Chemical burns, and especially alkali burns, can be serious because ocular penetration occurs quickly and ischaemic necrosis can result ( Figure 49.24 ). Immediate copious irrigation until the pH is neutral will ensure that the chemical is diluted as much as possible, and all particles should be removed from the fornices. Treatment can then be continued as with thermal burns. Well-fitting goggles should prevent such injuries.
Figure 49.24
Chemical burn showing conjunctival necrosis.
Burns
Radiation burns Corneal injury may occur after exposure to ultraviolet radia - tion, for example after arc welding or excessive sunlight (snow blindness) and sun lamps. Such burns cause intense gritty burning pain and photophobia as a result of  keratitis (corneal inflammation), which starts some hours after exposur e. Mydri - atic and local steroids with antibiotic drops ease the condition, and healing usually occurs after 24 hours. Thermal burns If  these involve the full thickness of  the lids, corneal scarring may occur from exposure and immediate corneal protection is necessary . A splash of  molten metal may cause marked local necrosis and may lead to permanent corneal scarring. Treatment is to remove any debris by irrigation and to instil local atropine, antibiotics and steroids to prevent superadded infection and scarring. Lid reconstruction may be necessary . Chemical burns Chemical burns, and especially alkali burns, can be serious because ocular penetration occurs quickly and ischaemic necrosis can result ( Figure 49.24 ). Immediate copious irrigation until the pH is neutral will ensure that the chemical is diluted as much as possible, and all particles should be removed from the fornices. Treatment can then be continued as with thermal burns. Well-fitting goggles should prevent such injuries.
Figure 49.24
Chemical burn showing conjunctival necrosis.
Burns
Radiation burns Corneal injury may occur after exposure to ultraviolet radia - tion, for example after arc welding or excessive sunlight (snow blindness) and sun lamps. Such burns cause intense gritty burning pain and photophobia as a result of  keratitis (corneal inflammation), which starts some hours after exposur e. Mydri - atic and local steroids with antibiotic drops ease the condition, and healing usually occurs after 24 hours. Thermal burns If  these involve the full thickness of  the lids, corneal scarring may occur from exposure and immediate corneal protection is necessary . A splash of  molten metal may cause marked local necrosis and may lead to permanent corneal scarring. Treatment is to remove any debris by irrigation and to instil local atropine, antibiotics and steroids to prevent superadded infection and scarring. Lid reconstruction may be necessary . Chemical burns Chemical burns, and especially alkali burns, can be serious because ocular penetration occurs quickly and ischaemic necrosis can result ( Figure 49.24 ). Immediate copious irrigation until the pH is neutral will ensure that the chemical is diluted as much as possible, and all particles should be removed from the fornices. Treatment can then be continued as with thermal burns. Well-fitting goggles should prevent such injuries.
Figure 49.24
Chemical burn showing conjunctival necrosis.

Conjunctivitis
Conjunctivitis
Symptoms are grittiness, redness and discharge. Causes are infective, chemical, allergic or traumatic. In the newborn it can be serious; gonococcal and chlamydial infection must be excluded. Bacterial conjunctivitis is purulent, usually self- limiting and treated with topical broad-spectrum antibiotics. Chlamydial and adenovirus infections must be considered. Adenoviral infections are common and usually a ff ect one eye much more in severity and onset, tending to be more watery than sticky , and are often associated with a palpable preauricular gland. V ernal conjunctivitis ( Figure 49.25 ) is a form of  allergic conjunctivitis that is characterised by itchy eyes, usually worse Moritz Kaposi , 1837–1902, Professor of  Dermatology , Vienna, Austria, described pigmented sarcoma of  the skin in 1872. allergic problems such as hay fe ver. Clinically , most signs are under the upper lid, which may have a cobblestone appearance instead of  a smooth surface. Giant papillary conjunctivitis with large papillae under the upper lid may be seen in soft contact lens wearers. This is usu - ally caused by an allergy to the sterilising solutions and lens protein and may be helped by either using a preservative-fr ee solution or using daily-wear disposable lenses. Kaposi’s sarcoma, often associated with human immuno - deficiency virus (HIV) infection, can rar ely present like a sub - conjunctival haemorrhage ( Figure 49.26 ). Considerable conjunctival and corneal irritation can be caused by the lids turning in (entropion) ( Figure 49.27 ) or turning out (ectropion) ( Figures 49.28 and 49.29 ), and by ingrowing lashes. T he lids should be repaired surgically to their normal position.
Figure 49.25
Vernal conjunctivitis (spring catarrh) showing cobble
stone appearance under the upper lid.
Figure 49.26
Kaposi’s sarcoma of conjunctiva.
Vision is not commonly a ff ected in conjunctivitis but, with some viral infections, a keratitis may be present and result in visual impairment and pain. All of  the other conditions below are painful and usually a ff ect vision. Rose Bengal (or Bengal Rose) is dichlorotetraiodofluorescein. Hulusi Behçet , 1889–1948, Professor of  Dermatology , Istanbul, Turkey , described this disease in 1937. Hans Conrad Julius Reiter , 1881–1968, President of  the Health Service and Honorary Professor of  Hygiene at the University of  Berlin, Germany , described this disease in 1916. Herpes simplex infection presents as a dendritic (branching) ulcer, shown easily by staining with fluorescein or Rose Bengal. It is treated with aciclovir ointment five times per day . The use of  steroid drops must be avoided as this can make the condition much worse ( Figure 49.30 ). Corneal ulceration may occur as a result of  ingrowing lashes or corneal foreign bodies, marginal ulceration and infected abrasions. Infected ulcers can occur in patients wear - ing soft contact lenses or elderly immunocompromised indi - viduals. Herpes zoster (shingles) may a ff ect the ophthalmic division of  cranial nerve V and can give rise to a keratitis and uveitis. It is important to avoid the use of  steroid drops until a diagnosis has been made. Local anaesthetic drops should also not be given on a regular basis.
Figure 49.27
Entropion (courtesy of J Beare, FRCS).
Figure 49.28
Ectropion, lower lid (courtesy of J Beare, FRCS).
Figure 49.29
Ectropion, upper lid – chronic staphylococcal infection
(courtesy of J Beare, FRCS).
Conjunctivitis
Symptoms are grittiness, redness and discharge. Causes are infective, chemical, allergic or traumatic. In the newborn it can be serious; gonococcal and chlamydial infection must be excluded. Bacterial conjunctivitis is purulent, usually self- limiting and treated with topical broad-spectrum antibiotics. Chlamydial and adenovirus infections must be considered. Adenoviral infections are common and usually a ff ect one eye much more in severity and onset, tending to be more watery than sticky , and are often associated with a palpable preauricular gland. V ernal conjunctivitis ( Figure 49.25 ) is a form of  allergic conjunctivitis that is characterised by itchy eyes, usually worse Moritz Kaposi , 1837–1902, Professor of  Dermatology , Vienna, Austria, described pigmented sarcoma of  the skin in 1872. allergic problems such as hay fe ver. Clinically , most signs are under the upper lid, which may have a cobblestone appearance instead of  a smooth surface. Giant papillary conjunctivitis with large papillae under the upper lid may be seen in soft contact lens wearers. This is usu - ally caused by an allergy to the sterilising solutions and lens protein and may be helped by either using a preservative-fr ee solution or using daily-wear disposable lenses. Kaposi’s sarcoma, often associated with human immuno - deficiency virus (HIV) infection, can rar ely present like a sub - conjunctival haemorrhage ( Figure 49.26 ). Considerable conjunctival and corneal irritation can be caused by the lids turning in (entropion) ( Figure 49.27 ) or turning out (ectropion) ( Figures 49.28 and 49.29 ), and by ingrowing lashes. T he lids should be repaired surgically to their normal position.
Figure 49.25
Vernal conjunctivitis (spring catarrh) showing cobble
stone appearance under the upper lid.
Figure 49.26
Kaposi’s sarcoma of conjunctiva.
Vision is not commonly a ff ected in conjunctivitis but, with some viral infections, a keratitis may be present and result in visual impairment and pain. All of  the other conditions below are painful and usually a ff ect vision. Rose Bengal (or Bengal Rose) is dichlorotetraiodofluorescein. Hulusi Behçet , 1889–1948, Professor of  Dermatology , Istanbul, Turkey , described this disease in 1937. Hans Conrad Julius Reiter , 1881–1968, President of  the Health Service and Honorary Professor of  Hygiene at the University of  Berlin, Germany , described this disease in 1916. Herpes simplex infection presents as a dendritic (branching) ulcer, shown easily by staining with fluorescein or Rose Bengal. It is treated with aciclovir ointment five times per day . The use of  steroid drops must be avoided as this can make the condition much worse ( Figure 49.30 ). Corneal ulceration may occur as a result of  ingrowing lashes or corneal foreign bodies, marginal ulceration and infected abrasions. Infected ulcers can occur in patients wear - ing soft contact lenses or elderly immunocompromised indi - viduals. Herpes zoster (shingles) may a ff ect the ophthalmic division of  cranial nerve V and can give rise to a keratitis and uveitis. It is important to avoid the use of  steroid drops until a diagnosis has been made. Local anaesthetic drops should also not be given on a regular basis.
Figure 49.27
Entropion (courtesy of J Beare, FRCS).
Figure 49.28
Ectropion, lower lid (courtesy of J Beare, FRCS).
Figure 49.29
Ectropion, upper lid – chronic staphylococcal infection
(courtesy of J Beare, FRCS).
Conjunctivitis
Symptoms are grittiness, redness and discharge. Causes are infective, chemical, allergic or traumatic. In the newborn it can be serious; gonococcal and chlamydial infection must be excluded. Bacterial conjunctivitis is purulent, usually self- limiting and treated with topical broad-spectrum antibiotics. Chlamydial and adenovirus infections must be considered. Adenoviral infections are common and usually a ff ect one eye much more in severity and onset, tending to be more watery than sticky , and are often associated with a palpable preauricular gland. V ernal conjunctivitis ( Figure 49.25 ) is a form of  allergic conjunctivitis that is characterised by itchy eyes, usually worse Moritz Kaposi , 1837–1902, Professor of  Dermatology , Vienna, Austria, described pigmented sarcoma of  the skin in 1872. allergic problems such as hay fe ver. Clinically , most signs are under the upper lid, which may have a cobblestone appearance instead of  a smooth surface. Giant papillary conjunctivitis with large papillae under the upper lid may be seen in soft contact lens wearers. This is usu - ally caused by an allergy to the sterilising solutions and lens protein and may be helped by either using a preservative-fr ee solution or using daily-wear disposable lenses. Kaposi’s sarcoma, often associated with human immuno - deficiency virus (HIV) infection, can rar ely present like a sub - conjunctival haemorrhage ( Figure 49.26 ). Considerable conjunctival and corneal irritation can be caused by the lids turning in (entropion) ( Figure 49.27 ) or turning out (ectropion) ( Figures 49.28 and 49.29 ), and by ingrowing lashes. T he lids should be repaired surgically to their normal position.
Figure 49.25
Vernal conjunctivitis (spring catarrh) showing cobble
stone appearance under the upper lid.
Figure 49.26
Kaposi’s sarcoma of conjunctiva.
Vision is not commonly a ff ected in conjunctivitis but, with some viral infections, a keratitis may be present and result in visual impairment and pain. All of  the other conditions below are painful and usually a ff ect vision. Rose Bengal (or Bengal Rose) is dichlorotetraiodofluorescein. Hulusi Behçet , 1889–1948, Professor of  Dermatology , Istanbul, Turkey , described this disease in 1937. Hans Conrad Julius Reiter , 1881–1968, President of  the Health Service and Honorary Professor of  Hygiene at the University of  Berlin, Germany , described this disease in 1916. Herpes simplex infection presents as a dendritic (branching) ulcer, shown easily by staining with fluorescein or Rose Bengal. It is treated with aciclovir ointment five times per day . The use of  steroid drops must be avoided as this can make the condition much worse ( Figure 49.30 ). Corneal ulceration may occur as a result of  ingrowing lashes or corneal foreign bodies, marginal ulceration and infected abrasions. Infected ulcers can occur in patients wear - ing soft contact lenses or elderly immunocompromised indi - viduals. Herpes zoster (shingles) may a ff ect the ophthalmic division of  cranial nerve V and can give rise to a keratitis and uveitis. It is important to avoid the use of  steroid drops until a diagnosis has been made. Local anaesthetic drops should also not be given on a regular basis.
Figure 49.27
Entropion (courtesy of J Beare, FRCS).
Figure 49.28
Ectropion, lower lid (courtesy of J Beare, FRCS).
Figure 49.29
Ectropion, upper lid – chronic staphylococcal infection
(courtesy of J Beare, FRCS).

DIFFERENTIAL DIAGNOSIS OF THE ACUTE RED EYE
DIFFERENTIAL DIAGNOSIS OF THE ACUTE RED EYE
This is important in the management of  minor ocular complaints and the recognition of  conditions that require expert attention. Possible causes of  the acute red eye include: /uni25CF subconjunctival haemorrhage; /uni25CF conjunctivitis; /uni25CF keratitis; /uni25CF uveitis; /uni25CF episcleritis and scleritis; /uni25CF acute glaucoma. Any condition with pain, visual impairment or a pupil abnormality suggests a more serious diagnosis. DIFFERENTIAL DIAGNOSIS OF THE ACUTE RED EYE
This is important in the management of  minor ocular complaints and the recognition of  conditions that require expert attention. Possible causes of  the acute red eye include: /uni25CF subconjunctival haemorrhage; /uni25CF conjunctivitis; /uni25CF keratitis; /uni25CF uveitis; /uni25CF episcleritis and scleritis; /uni25CF acute glaucoma. Any condition with pain, visual impairment or a pupil abnormality suggests a more serious diagnosis. DIFFERENTIAL DIAGNOSIS OF THE ACUTE RED EYE
This is important in the management of  minor ocular complaints and the recognition of  conditions that require expert attention. Possible causes of  the acute red eye include: /uni25CF subconjunctival haemorrhage; /uni25CF conjunctivitis; /uni25CF keratitis; /uni25CF uveitis; /uni25CF episcleritis and scleritis; /uni25CF acute glaucoma. Any condition with pain, visual impairment or a pupil abnormality suggests a more serious diagnosis.

Diagnostic aids
Diagnostic aids
Diagnostic aids include radiography , CT , MRI, ultrasonogra phy and, less commonly , tomography and orbital venography . Diagnostic aids
Diagnostic aids include radiography , CT , MRI, ultrasonogra phy and, less commonly , tomography and orbital venography . Diagnostic aids
Diagnostic aids include radiography , CT , MRI, ultrasonogra phy and, less commonly , tomography and orbital venography .

FURTHER READING
FURTHER READING
Denniston A, Murray P . Oxford handbook of  ophthalmology , 4th edn. Ox - ford: Oxford University Press, 2018. Friedman NJ, Kaiser PJ, Trattler WB. Review of  ophthalmology , 3rd edn. Edinburgh: Elsevier, 2017. Jackson TL. Moorfields manual of  ophthalmology , 3rd edn. London: JP Medical Ltd, 2019. Salmon J. Kanski’s clinical ophthalmology: a systematic approach, 9th edn. Edinburgh: Elsevier, 2019. Wills Eye Hospital. The Wills eye manual: o ffi ce and emergency room diag - nosis and treatment of  eye disease , 8th edn. Philadelphia, PA: Walters Kluwer, 2021. FURTHER READING
Denniston A, Murray P . Oxford handbook of  ophthalmology , 4th edn. Ox - ford: Oxford University Press, 2018. Friedman NJ, Kaiser PJ, Trattler WB. Review of  ophthalmology , 3rd edn. Edinburgh: Elsevier, 2017. Jackson TL. Moorfields manual of  ophthalmology , 3rd edn. London: JP Medical Ltd, 2019. Salmon J. Kanski’s clinical ophthalmology: a systematic approach, 9th edn. Edinburgh: Elsevier, 2019. Wills Eye Hospital. The Wills eye manual: o ffi ce and emergency room diag - nosis and treatment of  eye disease , 8th edn. Philadelphia, PA: Walters Kluwer, 2021. FURTHER READING
Denniston A, Murray P . Oxford handbook of  ophthalmology , 4th edn. Ox - ford: Oxford University Press, 2018. Friedman NJ, Kaiser PJ, Trattler WB. Review of  ophthalmology , 3rd edn. Edinburgh: Elsevier, 2017. Jackson TL. Moorfields manual of  ophthalmology , 3rd edn. London: JP Medical Ltd, 2019. Salmon J. Kanski’s clinical ophthalmology: a systematic approach, 9th edn. Edinburgh: Elsevier, 2019. Wills Eye Hospital. The Wills eye manual: o ffi ce and emergency room diag - nosis and treatment of  eye disease , 8th edn. Philadelphia, PA: Walters Kluwer, 2021.

INJURIES INVOL VING THE EYE AND ADJACENT STRUCTURE
INJURIES INVOL VING THE EYE AND ADJACENT STRUCTURES Corneal abrasions and ulceration
The cornea is frequently damaged by direct trauma or by foreign bodies ( Figure 49.16 ). Ulceration can occur with infection, exposure (for example in severely ill patients with incomplete eye closure) or after damage to the facial nerve. Postherpetic ulceration is common and serious if  not treated. Fluorescein instillation illuminated by blue light shows up corneal ulceration at an early stage, with areas of  epithelial loss fluorescing green. Treatment of  sterile corneal abrasions or exposure is by topical lubrication or padding of  the eye. If  bacterial infec tion is suspected, a swab or scrape may be performed for microbiological diagnosis and topical antibiotics such as 0.5% chloramphenicol or ofloxacin eye dr ops are commonly used. Jean Descemet , 1732–1810, French physician and botanist. The eye is made more comfortable by the use of  mydriatics such as cyclopentolate to reduce photophobia. Herpes sim - plex dendritic ulcers are treated with aciclovir ointment. In countries in the Far and Middle East, chronic infection with trachoma can cause corneal opacification and blindness, although the worldwide incidence of  this condition is falling. Corneal grafting is the only cure for an opaque cor nea. Until recently , full-thickness penetrating keratoplasty was the only corneal graft technique. For some conditions this has largely been replaced by lamellar or partial-thickness graft surgery , in a technique termed DSEK or ‘Descemet’s stripping endothe - lial keratoplasty’. However, penetrating keratoplasty remains the treatment of  choice for severe corneal damage due to infection or injury . Rarely , osteo-odonto-keratoprosthesis can be attempted in very severe cases of opaque corneas that are not suitable for grafting. Artificial corneal prostheses have also been developed. Acanthamoeba is a rare serious cause of  cor - neal infection. This infection usually follows the use of contact lenses. Specialist management and treatment is recommended. Summary box 49.3 Corneal abrasions /uni25CF /uni25CF /uni25CF
Figure 49.16
Corneal foreign body.
A drop of
/f_l
uorescein dye illuminated by a blue light reveals
even the smallest corneal abrasion
Corneal ulcers are often more serious in contact lens wearers
and require prompt assessment and treatment
Development of white in
/f_i
ltrate in/around a corneal abrasion is
a sign of infection
INJURIES INVOL VING THE EYE AND ADJACENT STRUCTURES Corneal abrasions and ulceration
The cornea is frequently damaged by direct trauma or by foreign bodies ( Figure 49.16 ). Ulceration can occur with infection, exposure (for example in severely ill patients with incomplete eye closure) or after damage to the facial nerve. Postherpetic ulceration is common and serious if  not treated. Fluorescein instillation illuminated by blue light shows up corneal ulceration at an early stage, with areas of  epithelial loss fluorescing green. Treatment of  sterile corneal abrasions or exposure is by topical lubrication or padding of  the eye. If  bacterial infec tion is suspected, a swab or scrape may be performed for microbiological diagnosis and topical antibiotics such as 0.5% chloramphenicol or ofloxacin eye dr ops are commonly used. Jean Descemet , 1732–1810, French physician and botanist. The eye is made more comfortable by the use of  mydriatics such as cyclopentolate to reduce photophobia. Herpes sim - plex dendritic ulcers are treated with aciclovir ointment. In countries in the Far and Middle East, chronic infection with trachoma can cause corneal opacification and blindness, although the worldwide incidence of  this condition is falling. Corneal grafting is the only cure for an opaque cor nea. Until recently , full-thickness penetrating keratoplasty was the only corneal graft technique. For some conditions this has largely been replaced by lamellar or partial-thickness graft surgery , in a technique termed DSEK or ‘Descemet’s stripping endothe - lial keratoplasty’. However, penetrating keratoplasty remains the treatment of  choice for severe corneal damage due to infection or injury . Rarely , osteo-odonto-keratoprosthesis can be attempted in very severe cases of opaque corneas that are not suitable for grafting. Artificial corneal prostheses have also been developed. Acanthamoeba is a rare serious cause of  cor - neal infection. This infection usually follows the use of contact lenses. Specialist management and treatment is recommended. Summary box 49.3 Corneal abrasions /uni25CF /uni25CF /uni25CF
Figure 49.16
Corneal foreign body.
A drop of
/f_l
uorescein dye illuminated by a blue light reveals
even the smallest corneal abrasion
Corneal ulcers are often more serious in contact lens wearers
and require prompt assessment and treatment
Development of white in
/f_i
ltrate in/around a corneal abrasion is
a sign of infection

INJURIES INVOL VING THE EYE AND ADJACENT STRUCTURES Corneal abrasions and ulceration
INJURIES INVOL VING THE EYE AND ADJACENT STRUCTURES Corneal abrasions and ulceration
The cornea is frequently damaged by direct trauma or by foreign bodies ( Figure 49.16 ). Ulceration can occur with infection, exposure (for example in severely ill patients with incomplete eye closure) or after damage to the facial nerve. Postherpetic ulceration is common and serious if  not treated. Fluorescein instillation illuminated by blue light shows up corneal ulceration at an early stage, with areas of  epithelial loss fluorescing green. Treatment of  sterile corneal abrasions or exposure is by topical lubrication or padding of  the eye. If  bacterial infec tion is suspected, a swab or scrape may be performed for microbiological diagnosis and topical antibiotics such as 0.5% chloramphenicol or ofloxacin eye dr ops are commonly used. Jean Descemet , 1732–1810, French physician and botanist. The eye is made more comfortable by the use of  mydriatics such as cyclopentolate to reduce photophobia. Herpes sim - plex dendritic ulcers are treated with aciclovir ointment. In countries in the Far and Middle East, chronic infection with trachoma can cause corneal opacification and blindness, although the worldwide incidence of  this condition is falling. Corneal grafting is the only cure for an opaque cor nea. Until recently , full-thickness penetrating keratoplasty was the only corneal graft technique. For some conditions this has largely been replaced by lamellar or partial-thickness graft surgery , in a technique termed DSEK or ‘Descemet’s stripping endothe - lial keratoplasty’. However, penetrating keratoplasty remains the treatment of  choice for severe corneal damage due to infection or injury . Rarely , osteo-odonto-keratoprosthesis can be attempted in very severe cases of opaque corneas that are not suitable for grafting. Artificial corneal prostheses have also been developed. Acanthamoeba is a rare serious cause of  cor - neal infection. This infection usually follows the use of contact lenses. Specialist management and treatment is recommended. Summary box 49.3 Corneal abrasions /uni25CF /uni25CF /uni25CF
Figure 49.16
Corneal foreign body.
A drop of
/f_l
uorescein dye illuminated by a blue light reveals
even the smallest corneal abrasion
Corneal ulcers are often more serious in contact lens wearers
and require prompt assessment and treatment
Development of white in
/f_i
ltrate in/around a corneal abrasion is
a sign of infection

INTRAOCULAR TUMOURS Children
INTRAOCULAR TUMOURS Children
Retinoblastoma, the most common ocular malignancy of childhood, is a malignant tumour of the retina that can be bilateral in around one-third of  cases. Half  of  cases are heredi tary (autosomal dominant) and are due to mutation of  the gene on chromosome 13; children with a family history should be carefully monitored from birth. Remaining cases occur sporadically . Inherited retinoblastoma is more likely to be bilateral. Retinoblastoma is often not spotted until the tumour fills the globe and presents as a white reflex in the pupil or as a squint ( Figure 49.13 ). The di ff erential diagnosis includes reti - nopathy of  prematurity , persistent fetal vasculature (PFV) and - intraocular infections. If  the tumour is large, enucleation may be required, but radiotherapy , cryotherap y , chemotherapy or laser treatment can cure small lesions. Liaison with a paediatric oncologist is essential. Summary box 49.2 Intraocular tumours /uni25CF /uni25CF - RB1
Figure 49.12
Capillary haemangioma in a child. An orbital venogram
demonstrates displacement of the second part of the superior oph
thalmic vein (arrow) (courtesy of Dr Glyn Lloyd).
Figure 49.13
Retinoblastoma giving rise to a white pupillary re
/f_l
ex.
This child was
/f_i
rst seen with a convergent squint and discharged
without a fundus examination. He was next seen many years later
with a ‘white re
/f_l
ex’ and died soon after diagnosis (courtesy of MA
Bedford, FRCS).
Any child with a white pupil (leukokoria) should be referred
to an ophthalmologist to exclude retinoblastoma, although
congenital cataracts may also cause this sign
A blind painful eye may hide a melanoma or other ocular
tumour
INTRAOCULAR TUMOURS Children
Retinoblastoma, the most common ocular malignancy of childhood, is a malignant tumour of the retina that can be bilateral in around one-third of  cases. Half  of  cases are heredi tary (autosomal dominant) and are due to mutation of  the gene on chromosome 13; children with a family history should be carefully monitored from birth. Remaining cases occur sporadically . Inherited retinoblastoma is more likely to be bilateral. Retinoblastoma is often not spotted until the tumour fills the globe and presents as a white reflex in the pupil or as a squint ( Figure 49.13 ). The di ff erential diagnosis includes reti - nopathy of  prematurity , persistent fetal vasculature (PFV) and - intraocular infections. If  the tumour is large, enucleation may be required, but radiotherapy , cryotherap y , chemotherapy or laser treatment can cure small lesions. Liaison with a paediatric oncologist is essential. Summary box 49.2 Intraocular tumours /uni25CF /uni25CF - RB1
Figure 49.12
Capillary haemangioma in a child. An orbital venogram
demonstrates displacement of the second part of the superior oph
thalmic vein (arrow) (courtesy of Dr Glyn Lloyd).
Figure 49.13
Retinoblastoma giving rise to a white pupillary re
/f_l
ex.
This child was
/f_i
rst seen with a convergent squint and discharged
without a fundus examination. He was next seen many years later
with a ‘white re
/f_l
ex’ and died soon after diagnosis (courtesy of MA
Bedford, FRCS).
Any child with a white pupil (leukokoria) should be referred
to an ophthalmologist to exclude retinoblastoma, although
congenital cataracts may also cause this sign
A blind painful eye may hide a melanoma or other ocular
tumour
INTRAOCULAR TUMOURS Children
Retinoblastoma, the most common ocular malignancy of childhood, is a malignant tumour of the retina that can be bilateral in around one-third of  cases. Half  of  cases are heredi tary (autosomal dominant) and are due to mutation of  the gene on chromosome 13; children with a family history should be carefully monitored from birth. Remaining cases occur sporadically . Inherited retinoblastoma is more likely to be bilateral. Retinoblastoma is often not spotted until the tumour fills the globe and presents as a white reflex in the pupil or as a squint ( Figure 49.13 ). The di ff erential diagnosis includes reti - nopathy of  prematurity , persistent fetal vasculature (PFV) and - intraocular infections. If  the tumour is large, enucleation may be required, but radiotherapy , cryotherap y , chemotherapy or laser treatment can cure small lesions. Liaison with a paediatric oncologist is essential. Summary box 49.2 Intraocular tumours /uni25CF /uni25CF - RB1
Figure 49.12
Capillary haemangioma in a child. An orbital venogram
demonstrates displacement of the second part of the superior oph
thalmic vein (arrow) (courtesy of Dr Glyn Lloyd).
Figure 49.13
Retinoblastoma giving rise to a white pupillary re
/f_l
ex.
This child was
/f_i
rst seen with a convergent squint and discharged
without a fundus examination. He was next seen many years later
with a ‘white re
/f_l
ex’ and died soon after diagnosis (courtesy of MA
Bedford, FRCS).
Any child with a white pupil (leukokoria) should be referred
to an ophthalmologist to exclude retinoblastoma, although
congenital cataracts may also cause this sign
A blind painful eye may hide a melanoma or other ocular
tumour

Incision and curettage of chalazion (meibomian cys
Incision and curettage of chalazion (meibomian cyst)
The lid margin is everted to allow the application of  a meibomian clamp. The ring of  the clamp is placed on the incision is made with a small blade in the axis of  the gland. The herniating granulomatous tissue is removed with a curette and the cavity is scraped clean. Recurr ent cysts may have to have the cyst wall dissected away with scissors. A biopsy may be necessary in atypical or recurrent cysts to exclude malignant change. Incision and curettage of chalazion (meibomian cyst)
The lid margin is everted to allow the application of  a meibomian clamp. The ring of  the clamp is placed on the incision is made with a small blade in the axis of  the gland. The herniating granulomatous tissue is removed with a curette and the cavity is scraped clean. Recurr ent cysts may have to have the cyst wall dissected away with scissors. A biopsy may be necessary in atypical or recurrent cysts to exclude malignant change.

Incision and curettage of chalazion (meibomian cyst)
Incision and curettage of chalazion (meibomian cyst)
The lid margin is everted to allow the application of  a meibomian clamp. The ring of  the clamp is placed on the incision is made with a small blade in the axis of  the gland. The herniating granulomatous tissue is removed with a curette and the cavity is scraped clean. Recurr ent cysts may have to have the cyst wall dissected away with scissors. A biopsy may be necessary in atypical or recurrent cysts to exclude malignant change.

Intraocular foreign bodies
Intraocular foreign bodies
Intraocular foreign bodies must always be excluded when patients attend the accident and emergency department with an eye injury and a history of  working with a hammer and chisel or a history of  a potentially high-velocity injury . Radio - graphy of  the orbits must be performed. Ferrous and copper foreign bodies should always be removed, sometimes requiring the use of  a magnet. B-scan ultrasonography can also assist in localising foreign bodies when a vitreous haemorrhage or cata - ract is present. CT can be used, but MRI is contraindicated if a ferrous intraocular foreign body is suspected. Summary box 49.4 Penetrating eye injuries /uni25CF /uni25CF
A distorted and irregular pupil warrants the careful exclusion of
a penetrating eye injury
Avoid extensive eye examination if globe rupture is suspected
to avoid worsening the injury prior to surgical repair
Intraocular foreign bodies
Intraocular foreign bodies must always be excluded when patients attend the accident and emergency department with an eye injury and a history of  working with a hammer and chisel or a history of  a potentially high-velocity injury . Radio - graphy of  the orbits must be performed. Ferrous and copper foreign bodies should always be removed, sometimes requiring the use of  a magnet. B-scan ultrasonography can also assist in localising foreign bodies when a vitreous haemorrhage or cata - ract is present. CT can be used, but MRI is contraindicated if a ferrous intraocular foreign body is suspected. Summary box 49.4 Penetrating eye injuries /uni25CF /uni25CF
A distorted and irregular pupil warrants the careful exclusion of
a penetrating eye injury
Avoid extensive eye examination if globe rupture is suspected
to avoid worsening the injury prior to surgical repair
Intraocular foreign bodies
Intraocular foreign bodies must always be excluded when patients attend the accident and emergency department with an eye injury and a history of  working with a hammer and chisel or a history of  a potentially high-velocity injury . Radio - graphy of  the orbits must be performed. Ferrous and copper foreign bodies should always be removed, sometimes requiring the use of  a magnet. B-scan ultrasonography can also assist in localising foreign bodies when a vitreous haemorrhage or cata - ract is present. CT can be used, but MRI is contraindicated if a ferrous intraocular foreign body is suspected. Summary box 49.4 Penetrating eye injuries /uni25CF /uni25CF
A distorted and irregular pupil warrants the careful exclusion of
a penetrating eye injury
Avoid extensive eye examination if globe rupture is suspected
to avoid worsening the injury prior to surgical repair

Introduction
Introduction
No content extracted automatically.

LASERS IN OPHTHALMOLOGY
LASERS IN OPHTHALMOLOGY
Blue-green lasers (argon or frequency-doubled YAG) or diode lasers are used to treat the retina in diabetic retinopathy (pan-retinal photocoagulation for proliferative disease or focal treatment for leaky microaneurysms) and may also be used to close retinal tears or breaks that might lead to retinal detachment. Argon laser or selective laser trabeculoplasty can be used to open the drainage angle to control elevated intraocular pres - sure in open angle glaucoma. Trans-scleral diode photocoagu - lation of  the ciliar y body is used to treat refractory secondary glaucoma with uncontrolled ocular pressure. Laser iridotomy with the neodymium-doped YAG (Nd:YAG) laser is used to treat both the a ff ected and fellow eye in acute angle closur e glaucoma. The Nd:Y AG laser is also used to photodisrupt and clean an opaque posterior capsule, which occurs in 5–10% of  cases following cataract surgery . LASERS IN OPHTHALMOLOGY
Blue-green lasers (argon or frequency-doubled YAG) or diode lasers are used to treat the retina in diabetic retinopathy (pan-retinal photocoagulation for proliferative disease or focal treatment for leaky microaneurysms) and may also be used to close retinal tears or breaks that might lead to retinal detachment. Argon laser or selective laser trabeculoplasty can be used to open the drainage angle to control elevated intraocular pres - sure in open angle glaucoma. Trans-scleral diode photocoagu - lation of  the ciliar y body is used to treat refractory secondary glaucoma with uncontrolled ocular pressure. Laser iridotomy with the neodymium-doped YAG (Nd:YAG) laser is used to treat both the a ff ected and fellow eye in acute angle closur e glaucoma. The Nd:Y AG laser is also used to photodisrupt and clean an opaque posterior capsule, which occurs in 5–10% of  cases following cataract surgery . LASERS IN OPHTHALMOLOGY
Blue-green lasers (argon or frequency-doubled YAG) or diode lasers are used to treat the retina in diabetic retinopathy (pan-retinal photocoagulation for proliferative disease or focal treatment for leaky microaneurysms) and may also be used to close retinal tears or breaks that might lead to retinal detachment. Argon laser or selective laser trabeculoplasty can be used to open the drainage angle to control elevated intraocular pres - sure in open angle glaucoma. Trans-scleral diode photocoagu - lation of  the ciliar y body is used to treat refractory secondary glaucoma with uncontrolled ocular pressure. Laser iridotomy with the neodymium-doped YAG (Nd:YAG) laser is used to treat both the a ff ected and fellow eye in acute angle closur e glaucoma. The Nd:Y AG laser is also used to photodisrupt and clean an opaque posterior capsule, which occurs in 5–10% of  cases following cataract surgery .

Lacrimal system
Lacrimal system
The almond-shaped lacrimal gland lies under the upper outer orbital rim and opens into the upper conjunctival fornix through 10–15 ducts. Tears are swept across the globe by the lids and evaporate or pass into the upper and lower lid puncta, and then into the canaliculi to join the common canaliculus, which passes into the lacrimal sac under the medial canthal tendon. The sac is drained by the nasolacrimal duct into the nose, opening in the inferior meatus under the inferior turbi nate. Lacrimal system
The almond-shaped lacrimal gland lies under the upper outer orbital rim and opens into the upper conjunctival fornix through 10–15 ducts. Tears are swept across the globe by the lids and evaporate or pass into the upper and lower lid puncta, and then into the canaliculi to join the common canaliculus, which passes into the lacrimal sac under the medial canthal tendon. The sac is drained by the nasolacrimal duct into the nose, opening in the inferior meatus under the inferior turbi nate. Lacrimal system
The almond-shaped lacrimal gland lies under the upper outer orbital rim and opens into the upper conjunctival fornix through 10–15 ducts. Tears are swept across the globe by the lids and evaporate or pass into the upper and lower lid puncta, and then into the canaliculi to join the common canaliculus, which passes into the lacrimal sac under the medial canthal tendon. The sac is drained by the nasolacrimal duct into the nose, opening in the inferior meatus under the inferior turbi nate.

Learning objectives
Learning objectives
To understand and appreciate: The anatomy of the eye and orbit • The common ocular disorders and their symptoms and • speci /f_i c signs Learning objectives
To understand and appreciate: The anatomy of the eye and orbit • The common ocular disorders and their symptoms and • speci /f_i c signs Learning objectives
To understand and appreciate: The anatomy of the eye and orbit • The common ocular disorders and their symptoms and • speci /f_i c signs

Neurofibromatosis
Neurofibromatosis
Neurofibromatosis may also produce swellings above the eye. The diagnosis can usually be confirmed by an examination of the whole body , as there are often multiple lesions. Proptosis can also result ( Figure 49.3 ). Other ophthalmic features may be present. ),
Figure 49.3
Neuro
/f_i
broma in the orbit with proptosis, and also similar
lesions in the forehead.
Neurofibromatosis
Neurofibromatosis may also produce swellings above the eye. The diagnosis can usually be confirmed by an examination of the whole body , as there are often multiple lesions. Proptosis can also result ( Figure 49.3 ). Other ophthalmic features may be present. ),
Figure 49.3
Neuro
/f_i
broma in the orbit with proptosis, and also similar
lesions in the forehead.
Neurofibromatosis
Neurofibromatosis may also produce swellings above the eye. The diagnosis can usually be confirmed by an examination of the whole body , as there are often multiple lesions. Proptosis can also result ( Figure 49.3 ). Other ophthalmic features may be present. ),
Figure 49.3
Neuro
/f_i
broma in the orbit with proptosis, and also similar
lesions in the forehead.

OCULAR ANATOMY Adnexae
OCULAR ANATOMY Adnexae
The lids comprise skin, connective tissue, the orbicularis oculi (cranial nerve VII) and the tarsal plate, with multiple meibomian glands opening posterior to the lashes and lined with conjunctiva, which is reflected onto the sclera. The upper lid is elevated by the levator muscle (cranial nerve III) and has a horizontal strip of  sympathetically innervated Müller’s muscle, giving rise to 2 /uni00A0 mm of  ptosis in Horner’s syndrome. The frontalis muscle may also contribute to eyelid elevation, particularly when the levator muscle is weak. Both lids are attached to the orbital rim by the medial and lateral canthal tendons. Both have a rich vascular supply and are innervated by the V1 division of  the trigeminal nerve (cranial nerve V) above and the V2 division below . OCULAR ANATOMY Adnexae
The lids comprise skin, connective tissue, the orbicularis oculi (cranial nerve VII) and the tarsal plate, with multiple meibomian glands opening posterior to the lashes and lined with conjunctiva, which is reflected onto the sclera. The upper lid is elevated by the levator muscle (cranial nerve III) and has a horizontal strip of  sympathetically innervated Müller’s muscle, giving rise to 2 /uni00A0 mm of  ptosis in Horner’s syndrome. The frontalis muscle may also contribute to eyelid elevation, particularly when the levator muscle is weak. Both lids are attached to the orbital rim by the medial and lateral canthal tendons. Both have a rich vascular supply and are innervated by the V1 division of  the trigeminal nerve (cranial nerve V) above and the V2 division below . OCULAR ANATOMY Adnexae
The lids comprise skin, connective tissue, the orbicularis oculi (cranial nerve VII) and the tarsal plate, with multiple meibomian glands opening posterior to the lashes and lined with conjunctiva, which is reflected onto the sclera. The upper lid is elevated by the levator muscle (cranial nerve III) and has a horizontal strip of  sympathetically innervated Müller’s muscle, giving rise to 2 /uni00A0 mm of  ptosis in Horner’s syndrome. The frontalis muscle may also contribute to eyelid elevation, particularly when the levator muscle is weak. Both lids are attached to the orbital rim by the medial and lateral canthal tendons. Both have a rich vascular supply and are innervated by the V1 division of  the trigeminal nerve (cranial nerve V) above and the V2 division below .

Orbit
Orbit
The orbit is four-sided and pyramidal in structure, housing the globe, optic nerve, the four rectus and two oblique muscles, the lacrimal gland, orbital fat, the cranial nerves III–VI, the ophthalmic artery with its tributaries and the ophthalmic veins, which anastomose anteriorly with the face and posteriorly with the cranial cavity . Above is the frontal lobe of  the brain, temporally the temporal fossa, inferiorly the maxillary sinus and nasally the lacrimal sac and ethmoidal and sphenoidal air sinuses. The optic nerve passes through the optic canal to the chiasm, with other nerves and vessels passing through the superior ophthalmic fissure. Orbit
The orbit is four-sided and pyramidal in structure, housing the globe, optic nerve, the four rectus and two oblique muscles, the lacrimal gland, orbital fat, the cranial nerves III–VI, the ophthalmic artery with its tributaries and the ophthalmic veins, which anastomose anteriorly with the face and posteriorly with the cranial cavity . Above is the frontal lobe of  the brain, temporally the temporal fossa, inferiorly the maxillary sinus and nasally the lacrimal sac and ethmoidal and sphenoidal air sinuses. The optic nerve passes through the optic canal to the chiasm, with other nerves and vessels passing through the superior ophthalmic fissure. Orbit
The orbit is four-sided and pyramidal in structure, housing the globe, optic nerve, the four rectus and two oblique muscles, the lacrimal gland, orbital fat, the cranial nerves III–VI, the ophthalmic artery with its tributaries and the ophthalmic veins, which anastomose anteriorly with the face and posteriorly with the cranial cavity . Above is the frontal lobe of  the brain, temporally the temporal fossa, inferiorly the maxillary sinus and nasally the lacrimal sac and ethmoidal and sphenoidal air sinuses. The optic nerve passes through the optic canal to the chiasm, with other nerves and vessels passing through the superior ophthalmic fissure.

Orbital swellings
Orbital swellings
Orbital swellings result in displacement of  the globe and limitation of  movement. A full description of  orbital swellings is outside the realm of  this text, but some of  the most common causes include the following. /uni25CF Pseudoproptosis . This results from a large eyeball, as seen in congenital glaucoma or high myopia. /uni25CF Orbital inflammatory conditions that result in or bital cellulitis ( Figure 49.7 ). /uni25CF Haemorrhage after trauma or retrobulbar injection. /uni25CF Neoplasia a ff ecting the lacrimal gland, the optic nerve, the orbital walls or the nasal sinuses (e.g. glioma [neuro fibromatosis, Figure 49.3 ], meningioma and osteoma [ Figure 49.8 ]). /uni25CF Thyroid eye disease ( Figures 49.9–49.11 ). This is the most common cause of  unilateral and bilateral proptosis in adults and may occur in the absence of  active thyroid disease or after thyroidectomy . Management of  severe thy r oid eye disease may require large doses of  systemic ste roids, radiotherapy or even orbital lateral wall decompres sion if  the eyeball is threatened by exposure or optic nerve compression. The disease is often more severe in smokers and those with poorly controlled thyroid function. CT and - - - - -
Figure 49.7
Orbital cellulitis.
Figure 49.8
Radiograph showing an osteoma on the nasal side of the
orbit giving rise to proptosis.
Figure 49.9
Computed tomogram of the orbit in dysthyroid exoph
thalmos, showing swollen muscles (courtesy of Dr Glyn Lloyd).
Figure 49.10
Magnetic resonance imaging scan of a coronal view of
the orbit, showing enlarged muscles in thyroid disease (courtesy of Dr
Juliette Britton).
magnetic resonance imaging (MRI) scans are useful in diagnosis. MRI with short tau inversion recovery (STIR) sequences is particularly useful for identification of  active inflammation within the orbital tissues. /uni25CF Pseudotumour , or malignant lymphoma. /uni25CF Haemangiomas of  the orbit ( Figure 49.12 ). /uni25CF Tumour metastases . These are rare. In children they usually arise from neuroblastomas of  the adrenal gland, whereas in adults the oesophagus, stomach, breast and prostate can be sites of  primary lesions.
Figure 49.11
Exophthalmos in dysthyroid eye disease.
Orbital swellings
Orbital swellings result in displacement of  the globe and limitation of  movement. A full description of  orbital swellings is outside the realm of  this text, but some of  the most common causes include the following. /uni25CF Pseudoproptosis . This results from a large eyeball, as seen in congenital glaucoma or high myopia. /uni25CF Orbital inflammatory conditions that result in or bital cellulitis ( Figure 49.7 ). /uni25CF Haemorrhage after trauma or retrobulbar injection. /uni25CF Neoplasia a ff ecting the lacrimal gland, the optic nerve, the orbital walls or the nasal sinuses (e.g. glioma [neuro fibromatosis, Figure 49.3 ], meningioma and osteoma [ Figure 49.8 ]). /uni25CF Thyroid eye disease ( Figures 49.9–49.11 ). This is the most common cause of  unilateral and bilateral proptosis in adults and may occur in the absence of  active thyroid disease or after thyroidectomy . Management of  severe thy r oid eye disease may require large doses of  systemic ste roids, radiotherapy or even orbital lateral wall decompres sion if  the eyeball is threatened by exposure or optic nerve compression. The disease is often more severe in smokers and those with poorly controlled thyroid function. CT and - - - - -
Figure 49.7
Orbital cellulitis.
Figure 49.8
Radiograph showing an osteoma on the nasal side of the
orbit giving rise to proptosis.
Figure 49.9
Computed tomogram of the orbit in dysthyroid exoph
thalmos, showing swollen muscles (courtesy of Dr Glyn Lloyd).
Figure 49.10
Magnetic resonance imaging scan of a coronal view of
the orbit, showing enlarged muscles in thyroid disease (courtesy of Dr
Juliette Britton).
magnetic resonance imaging (MRI) scans are useful in diagnosis. MRI with short tau inversion recovery (STIR) sequences is particularly useful for identification of  active inflammation within the orbital tissues. /uni25CF Pseudotumour , or malignant lymphoma. /uni25CF Haemangiomas of  the orbit ( Figure 49.12 ). /uni25CF Tumour metastases . These are rare. In children they usually arise from neuroblastomas of  the adrenal gland, whereas in adults the oesophagus, stomach, breast and prostate can be sites of  primary lesions.
Figure 49.11
Exophthalmos in dysthyroid eye disease.
Orbital swellings
Orbital swellings result in displacement of  the globe and limitation of  movement. A full description of  orbital swellings is outside the realm of  this text, but some of  the most common causes include the following. /uni25CF Pseudoproptosis . This results from a large eyeball, as seen in congenital glaucoma or high myopia. /uni25CF Orbital inflammatory conditions that result in or bital cellulitis ( Figure 49.7 ). /uni25CF Haemorrhage after trauma or retrobulbar injection. /uni25CF Neoplasia a ff ecting the lacrimal gland, the optic nerve, the orbital walls or the nasal sinuses (e.g. glioma [neuro fibromatosis, Figure 49.3 ], meningioma and osteoma [ Figure 49.8 ]). /uni25CF Thyroid eye disease ( Figures 49.9–49.11 ). This is the most common cause of  unilateral and bilateral proptosis in adults and may occur in the absence of  active thyroid disease or after thyroidectomy . Management of  severe thy r oid eye disease may require large doses of  systemic ste roids, radiotherapy or even orbital lateral wall decompres sion if  the eyeball is threatened by exposure or optic nerve compression. The disease is often more severe in smokers and those with poorly controlled thyroid function. CT and - - - - -
Figure 49.7
Orbital cellulitis.
Figure 49.8
Radiograph showing an osteoma on the nasal side of the
orbit giving rise to proptosis.
Figure 49.9
Computed tomogram of the orbit in dysthyroid exoph
thalmos, showing swollen muscles (courtesy of Dr Glyn Lloyd).
Figure 49.10
Magnetic resonance imaging scan of a coronal view of
the orbit, showing enlarged muscles in thyroid disease (courtesy of Dr
Juliette Britton).
magnetic resonance imaging (MRI) scans are useful in diagnosis. MRI with short tau inversion recovery (STIR) sequences is particularly useful for identification of  active inflammation within the orbital tissues. /uni25CF Pseudotumour , or malignant lymphoma. /uni25CF Haemangiomas of  the orbit ( Figure 49.12 ). /uni25CF Tumour metastases . These are rare. In children they usually arise from neuroblastomas of  the adrenal gland, whereas in adults the oesophagus, stomach, breast and prostate can be sites of  primary lesions.
Figure 49.11
Exophthalmos in dysthyroid eye disease.

Other lid swellings
Other lid swellings
Other types of  lid swelling are less common. They include squamous cell carcinoma and malignant melanoma, sebaceous cyst, papilloma, keratoacanthoma, cyst of  Moll (sweat glands) ( Figure 49.6 ) or Zeis (sebaceous glands) and molluscum contagiosum. When molluscum contagiosum occurs on the lid margin, it can give rise to a mild viral chronic keratoconjunc - tivitis and should be curetted or excised. Carcinoma of  the meibomian glands and rhabdomyo - sarcomas are rare lesions; they need to be treated by radical excision. Atypical or meibomian cysts that recur should be biopsied to exclude sebaceous gland carcinoma.
Figure 49.6
Cyst of Moll.
Other lid swellings
Other types of  lid swelling are less common. They include squamous cell carcinoma and malignant melanoma, sebaceous cyst, papilloma, keratoacanthoma, cyst of  Moll (sweat glands) ( Figure 49.6 ) or Zeis (sebaceous glands) and molluscum contagiosum. When molluscum contagiosum occurs on the lid margin, it can give rise to a mild viral chronic keratoconjunc - tivitis and should be curetted or excised. Carcinoma of  the meibomian glands and rhabdomyo - sarcomas are rare lesions; they need to be treated by radical excision. Atypical or meibomian cysts that recur should be biopsied to exclude sebaceous gland carcinoma.
Figure 49.6
Cyst of Moll.
Other lid swellings
Other types of  lid swelling are less common. They include squamous cell carcinoma and malignant melanoma, sebaceous cyst, papilloma, keratoacanthoma, cyst of  Moll (sweat glands) ( Figure 49.6 ) or Zeis (sebaceous glands) and molluscum contagiosum. When molluscum contagiosum occurs on the lid margin, it can give rise to a mild viral chronic keratoconjunc - tivitis and should be curetted or excised. Carcinoma of  the meibomian glands and rhabdomyo - sarcomas are rare lesions; they need to be treated by radical excision. Atypical or meibomian cysts that recur should be biopsied to exclude sebaceous gland carcinoma.
Figure 49.6
Cyst of Moll.

PERIORBITAL AND ORBITAL SWELLINGS Swellings relate
PERIORBITAL AND ORBITAL SWELLINGS Swellings related to the supraorbital margin
Dermoid cysts Dermoid cysts are benign congenital choristomas of  the orbit that originate from fetal bone suture lines during development, most commonly the frontozygomatic suture ( Figure 49.2 although they may also occur more medially . Dermoid cysts account for about half  of  childhood orbital neoplasms and consist of  keratinised epithelium and adnexal structures such as sweat glands and hair follicles. They often cause a bony depression and they may have a dumbbell extension into the orbit, which is of particular importance should they need to be excised. Dermoid cysts can also erode the orbital plate of the frontal bone to become attached to dura; for this reason it is important to image the area by computed tomography (CT) before excision. Friedrich Schlemm , 1795–1858, Professor of  Anatomy , Berlin, Germany .
Figure 49.2
External angular dermoid.
PERIORBITAL AND ORBITAL SWELLINGS Swellings related to the supraorbital margin
Dermoid cysts Dermoid cysts are benign congenital choristomas of  the orbit that originate from fetal bone suture lines during development, most commonly the frontozygomatic suture ( Figure 49.2 although they may also occur more medially . Dermoid cysts account for about half  of  childhood orbital neoplasms and consist of  keratinised epithelium and adnexal structures such as sweat glands and hair follicles. They often cause a bony depression and they may have a dumbbell extension into the orbit, which is of particular importance should they need to be excised. Dermoid cysts can also erode the orbital plate of the frontal bone to become attached to dura; for this reason it is important to image the area by computed tomography (CT) before excision. Friedrich Schlemm , 1795–1858, Professor of  Anatomy , Berlin, Germany .
Figure 49.2
External angular dermoid.

PERIORBITAL AND ORBITAL SWELLINGS Swellings related to the supraorbital margin
PERIORBITAL AND ORBITAL SWELLINGS Swellings related to the supraorbital margin
Dermoid cysts Dermoid cysts are benign congenital choristomas of  the orbit that originate from fetal bone suture lines during development, most commonly the frontozygomatic suture ( Figure 49.2 although they may also occur more medially . Dermoid cysts account for about half  of  childhood orbital neoplasms and consist of  keratinised epithelium and adnexal structures such as sweat glands and hair follicles. They often cause a bony depression and they may have a dumbbell extension into the orbit, which is of particular importance should they need to be excised. Dermoid cysts can also erode the orbital plate of the frontal bone to become attached to dura; for this reason it is important to image the area by computed tomography (CT) before excision. Friedrich Schlemm , 1795–1858, Professor of  Anatomy , Berlin, Germany .
Figure 49.2
External angular dermoid.

Penetrating eye injuries
Penetrating eye injuries
These occur when the globe is penetrated, often in road tra ffi c and other major accidents ( Figure 49.23 ) and also in injuries from sharp instruments. The compulsory wearing of  seat belts in motor vehicles has substantially reduced the incidence of this type of  eye injury , by up to 73% in the UK. The pres - ence of  an irregular pupil suggests prolapse of  the iris and should arouse suspicion of  a penetrating injury . Treatment is prompt primary repair to restore the integrity of  the g lobe. not be attempted before anaesthesia because this may lead to further extrusion of  the intraocular contents. If  the fundal view is poor, ultrasonography and orbital imaging are indi - cated. Secondary corneal grafting, lensectomy and vitrectomy have considerably improved the visual prognosis; these must be done by an experienced eye surgeon. Injuries to the optic nerves must also be excluded in se vere accidents.
Figure 49.21
Retinal haemorrhage from a cricket bat injury (courtesy
of J Beare, FRCS).
Figure 49.22
Retinal dialysis after blunt ocular injury.
Figure 49.23
Facial lacerations from a windscreen injury. Beware of a
perforating eye injury.
Penetrating eye injuries
These occur when the globe is penetrated, often in road tra ffi c and other major accidents ( Figure 49.23 ) and also in injuries from sharp instruments. The compulsory wearing of  seat belts in motor vehicles has substantially reduced the incidence of this type of  eye injury , by up to 73% in the UK. The pres - ence of  an irregular pupil suggests prolapse of  the iris and should arouse suspicion of  a penetrating injury . Treatment is prompt primary repair to restore the integrity of  the g lobe. not be attempted before anaesthesia because this may lead to further extrusion of  the intraocular contents. If  the fundal view is poor, ultrasonography and orbital imaging are indi - cated. Secondary corneal grafting, lensectomy and vitrectomy have considerably improved the visual prognosis; these must be done by an experienced eye surgeon. Injuries to the optic nerves must also be excluded in se vere accidents.
Figure 49.21
Retinal haemorrhage from a cricket bat injury (courtesy
of J Beare, FRCS).
Figure 49.22
Retinal dialysis after blunt ocular injury.
Figure 49.23
Facial lacerations from a windscreen injury. Beware of a
perforating eye injury.
Penetrating eye injuries
These occur when the globe is penetrated, often in road tra ffi c and other major accidents ( Figure 49.23 ) and also in injuries from sharp instruments. The compulsory wearing of  seat belts in motor vehicles has substantially reduced the incidence of this type of  eye injury , by up to 73% in the UK. The pres - ence of  an irregular pupil suggests prolapse of  the iris and should arouse suspicion of  a penetrating injury . Treatment is prompt primary repair to restore the integrity of  the g lobe. not be attempted before anaesthesia because this may lead to further extrusion of  the intraocular contents. If  the fundal view is poor, ultrasonography and orbital imaging are indi - cated. Secondary corneal grafting, lensectomy and vitrectomy have considerably improved the visual prognosis; these must be done by an experienced eye surgeon. Injuries to the optic nerves must also be excluded in se vere accidents.
Figure 49.21
Retinal haemorrhage from a cricket bat injury (courtesy
of J Beare, FRCS).
Figure 49.22
Retinal dialysis after blunt ocular injury.
Figure 49.23
Facial lacerations from a windscreen injury. Beware of a
perforating eye injury.

RECENT DEVELOPMENTS IN EYE SURGERY
RECENT DEVELOPMENTS IN EYE SURGERY
In the last three decades, eye surgery has become a micro surgical specialty . Cataract surgery has been transformed by changes in local anaesthesia, implants, phacoemulsification and small-incision surgery , which allows compressible/foldable silicone or acrylic implants to be inserted through a 2-mm incision. The implant power can be more accurately measured by new formulae and the use of  A-scan ultrasonography or laser wavefront biometry , and multifocal and accommodative lenses are now available. An even more recent advance in cataract surgery is the development of femtosecond laser tech nology , which allows extremely controlled corneal incisions, lens capsule opening and lens fragmentation to be achieved automatically together with the facility to adjust the shape of the cornea at the time of  surgery to impro ve visual outcome for some patients. The extent to which this technology improves long-term visual outcomes remains to be seen. There are new treatments for eye disorders that involve abnormal growth of  blood vessels in the back of  the eye, such as the wet form of  age-related macular degeneration. Anti-v ascular endothelial growth factor (VEGF) antibodies, such as the drug ranibizumab, may be injected directly into the vitreous cavity to reduce new vessel proliferation. Intravitreal steroid injections or anti-VEGF agents are now also being used diabetic retinopathy or retinal vein occlusion. Developments in vitreous surgery have enabled membranes to be peeled o ff the retina and macular holes to be repaired, and have also incr eased success rates in retinal detachment sur - gery with the additional use of  gases and silicone oil or heavy liquid inserted into the vitreous cavity to tamponade the retina. Advances in technolog y have also led to the development of photosensitive chips and camera systems that can be implanted into the eye to restore some vision in patients with sev ere and otherwise untreatable macular diseases. Some paralytic squints can be helped by the use of  adjust - able sutures or injections of  botulinum toxin into the overact - ing muscles. Refractive errors can be treated by the excimer laser. These laser in situ keratomileusis (LASIK) sur - can be combined with gery , which involves cutting a corneal flap (by femtosecond laser or surgery) and performing the laser surgery at a deeper level. There have been some concerns about defective contrast sensitivity and problems with night vision after laser corr ec - tion of  myopia. Phakic implants have also been used to correct high refractive errors. Corneal topography aids the accuracy of  corneal and refractive surger y and the increased use and quality of  CT and MRI scans has revolutionised the diagnosis - of  orbital and intracranial lesions involving the optic pathways ( Figures 49.35–49.37 ). Fluorescein angiography and ocular coherence tomog - raphy (OCT) are invaluable in the diagnosis and treatment of  macular conditions. OCT angiography has recently been - developed; this allows assessment of the retinal microvascu - lature without the need for systemically administered agents. This technology may reduce the need for fluorescein angiog - raphy in the future. OCT as well as scanning laser polarimetry of  the retinal nerve fibre layer and Heidelber g retinal tomog - raphy (HRT) are widely used in the diagnosis and management of  glaucoma. Surgical glaucoma management is also devel - - oping rapidly . Trabeculectomy surgery , where eye pressur e is reduced by creating a fistula between the anterior chamber -
Figure 49.35
Magnetic resonance imaging scan, sagittal view. Cra
niopharyngioma. The mass in the suprasellar cistern is of high signal
intensity because of the proteinaceous
/f_l
uid that the cyst contains
(courtesy of Dr Juliette Britton).
George G Baerveldt , 1945–2021, ophthalmologist, Emeritus Professor of  Ophthalmology , UC Irvine, CA, USA. A Mateen Ahmed , contemporary , Nigerian ophthalmologist, based in California, USA, developed the shunt that was approved by the US Food and Drug Administration in 1993. Jacques Rene Tenon , 1724–1816, surgeon, La Salpêtrière, Paris, France. become more refined in recent years, with better control of wound healing using topical application of  antiscarring drugs such as mitomycin C. Alternatives to trabeculectomy have been developed using devices such as Baerveldt and Ahmed shunts that drain aqueous from the eye to lower the pressure. A new revolution is also under way using minimally invasive glaucoma surgical techniques, with a variety of  tiny devices now available to shunt aqueous and reduce eye pressure.
Figure 49.36
High-resolution computed tomography through the
orbits showing dense calci
/f_i
cation of the optic nerve sheaths typical
of optic nerve meningioma (courtesy of Dr Juliette Britton).
Figure 49.37
Axial enhanced magnetic resonance imaging scan
showing a mass involving the optic chiasma and extending down the
optic nerves and tracts.
RECENT DEVELOPMENTS IN EYE SURGERY
In the last three decades, eye surgery has become a micro surgical specialty . Cataract surgery has been transformed by changes in local anaesthesia, implants, phacoemulsification and small-incision surgery , which allows compressible/foldable silicone or acrylic implants to be inserted through a 2-mm incision. The implant power can be more accurately measured by new formulae and the use of  A-scan ultrasonography or laser wavefront biometry , and multifocal and accommodative lenses are now available. An even more recent advance in cataract surgery is the development of femtosecond laser tech nology , which allows extremely controlled corneal incisions, lens capsule opening and lens fragmentation to be achieved automatically together with the facility to adjust the shape of the cornea at the time of  surgery to impro ve visual outcome for some patients. The extent to which this technology improves long-term visual outcomes remains to be seen. There are new treatments for eye disorders that involve abnormal growth of  blood vessels in the back of  the eye, such as the wet form of  age-related macular degeneration. Anti-v ascular endothelial growth factor (VEGF) antibodies, such as the drug ranibizumab, may be injected directly into the vitreous cavity to reduce new vessel proliferation. Intravitreal steroid injections or anti-VEGF agents are now also being used diabetic retinopathy or retinal vein occlusion. Developments in vitreous surgery have enabled membranes to be peeled o ff the retina and macular holes to be repaired, and have also incr eased success rates in retinal detachment sur - gery with the additional use of  gases and silicone oil or heavy liquid inserted into the vitreous cavity to tamponade the retina. Advances in technolog y have also led to the development of photosensitive chips and camera systems that can be implanted into the eye to restore some vision in patients with sev ere and otherwise untreatable macular diseases. Some paralytic squints can be helped by the use of  adjust - able sutures or injections of  botulinum toxin into the overact - ing muscles. Refractive errors can be treated by the excimer laser. These laser in situ keratomileusis (LASIK) sur - can be combined with gery , which involves cutting a corneal flap (by femtosecond laser or surgery) and performing the laser surgery at a deeper level. There have been some concerns about defective contrast sensitivity and problems with night vision after laser corr ec - tion of  myopia. Phakic implants have also been used to correct high refractive errors. Corneal topography aids the accuracy of  corneal and refractive surger y and the increased use and quality of  CT and MRI scans has revolutionised the diagnosis - of  orbital and intracranial lesions involving the optic pathways ( Figures 49.35–49.37 ). Fluorescein angiography and ocular coherence tomog - raphy (OCT) are invaluable in the diagnosis and treatment of  macular conditions. OCT angiography has recently been - developed; this allows assessment of the retinal microvascu - lature without the need for systemically administered agents. This technology may reduce the need for fluorescein angiog - raphy in the future. OCT as well as scanning laser polarimetry of  the retinal nerve fibre layer and Heidelber g retinal tomog - raphy (HRT) are widely used in the diagnosis and management of  glaucoma. Surgical glaucoma management is also devel - - oping rapidly . Trabeculectomy surgery , where eye pressur e is reduced by creating a fistula between the anterior chamber -
Figure 49.35
Magnetic resonance imaging scan, sagittal view. Cra
niopharyngioma. The mass in the suprasellar cistern is of high signal
intensity because of the proteinaceous
/f_l
uid that the cyst contains
(courtesy of Dr Juliette Britton).
George G Baerveldt , 1945–2021, ophthalmologist, Emeritus Professor of  Ophthalmology , UC Irvine, CA, USA. A Mateen Ahmed , contemporary , Nigerian ophthalmologist, based in California, USA, developed the shunt that was approved by the US Food and Drug Administration in 1993. Jacques Rene Tenon , 1724–1816, surgeon, La Salpêtrière, Paris, France. become more refined in recent years, with better control of wound healing using topical application of  antiscarring drugs such as mitomycin C. Alternatives to trabeculectomy have been developed using devices such as Baerveldt and Ahmed shunts that drain aqueous from the eye to lower the pressure. A new revolution is also under way using minimally invasive glaucoma surgical techniques, with a variety of  tiny devices now available to shunt aqueous and reduce eye pressure.
Figure 49.36
High-resolution computed tomography through the
orbits showing dense calci
/f_i
cation of the optic nerve sheaths typical
of optic nerve meningioma (courtesy of Dr Juliette Britton).
Figure 49.37
Axial enhanced magnetic resonance imaging scan
showing a mass involving the optic chiasma and extending down the
optic nerves and tracts.
RECENT DEVELOPMENTS IN EYE SURGERY
In the last three decades, eye surgery has become a micro surgical specialty . Cataract surgery has been transformed by changes in local anaesthesia, implants, phacoemulsification and small-incision surgery , which allows compressible/foldable silicone or acrylic implants to be inserted through a 2-mm incision. The implant power can be more accurately measured by new formulae and the use of  A-scan ultrasonography or laser wavefront biometry , and multifocal and accommodative lenses are now available. An even more recent advance in cataract surgery is the development of femtosecond laser tech nology , which allows extremely controlled corneal incisions, lens capsule opening and lens fragmentation to be achieved automatically together with the facility to adjust the shape of the cornea at the time of  surgery to impro ve visual outcome for some patients. The extent to which this technology improves long-term visual outcomes remains to be seen. There are new treatments for eye disorders that involve abnormal growth of  blood vessels in the back of  the eye, such as the wet form of  age-related macular degeneration. Anti-v ascular endothelial growth factor (VEGF) antibodies, such as the drug ranibizumab, may be injected directly into the vitreous cavity to reduce new vessel proliferation. Intravitreal steroid injections or anti-VEGF agents are now also being used diabetic retinopathy or retinal vein occlusion. Developments in vitreous surgery have enabled membranes to be peeled o ff the retina and macular holes to be repaired, and have also incr eased success rates in retinal detachment sur - gery with the additional use of  gases and silicone oil or heavy liquid inserted into the vitreous cavity to tamponade the retina. Advances in technolog y have also led to the development of photosensitive chips and camera systems that can be implanted into the eye to restore some vision in patients with sev ere and otherwise untreatable macular diseases. Some paralytic squints can be helped by the use of  adjust - able sutures or injections of  botulinum toxin into the overact - ing muscles. Refractive errors can be treated by the excimer laser. These laser in situ keratomileusis (LASIK) sur - can be combined with gery , which involves cutting a corneal flap (by femtosecond laser or surgery) and performing the laser surgery at a deeper level. There have been some concerns about defective contrast sensitivity and problems with night vision after laser corr ec - tion of  myopia. Phakic implants have also been used to correct high refractive errors. Corneal topography aids the accuracy of  corneal and refractive surger y and the increased use and quality of  CT and MRI scans has revolutionised the diagnosis - of  orbital and intracranial lesions involving the optic pathways ( Figures 49.35–49.37 ). Fluorescein angiography and ocular coherence tomog - raphy (OCT) are invaluable in the diagnosis and treatment of  macular conditions. OCT angiography has recently been - developed; this allows assessment of the retinal microvascu - lature without the need for systemically administered agents. This technology may reduce the need for fluorescein angiog - raphy in the future. OCT as well as scanning laser polarimetry of  the retinal nerve fibre layer and Heidelber g retinal tomog - raphy (HRT) are widely used in the diagnosis and management of  glaucoma. Surgical glaucoma management is also devel - - oping rapidly . Trabeculectomy surgery , where eye pressur e is reduced by creating a fistula between the anterior chamber -
Figure 49.35
Magnetic resonance imaging scan, sagittal view. Cra
niopharyngioma. The mass in the suprasellar cistern is of high signal
intensity because of the proteinaceous
/f_l
uid that the cyst contains
(courtesy of Dr Juliette Britton).
George G Baerveldt , 1945–2021, ophthalmologist, Emeritus Professor of  Ophthalmology , UC Irvine, CA, USA. A Mateen Ahmed , contemporary , Nigerian ophthalmologist, based in California, USA, developed the shunt that was approved by the US Food and Drug Administration in 1993. Jacques Rene Tenon , 1724–1816, surgeon, La Salpêtrière, Paris, France. become more refined in recent years, with better control of wound healing using topical application of  antiscarring drugs such as mitomycin C. Alternatives to trabeculectomy have been developed using devices such as Baerveldt and Ahmed shunts that drain aqueous from the eye to lower the pressure. A new revolution is also under way using minimally invasive glaucoma surgical techniques, with a variety of  tiny devices now available to shunt aqueous and reduce eye pressure.
Figure 49.36
High-resolution computed tomography through the
orbits showing dense calci
/f_i
cation of the optic nerve sheaths typical
of optic nerve meningioma (courtesy of Dr Juliette Britton).
Figure 49.37
Axial enhanced magnetic resonance imaging scan
showing a mass involving the optic chiasma and extending down the
optic nerves and tracts.

SURGICAL PROCEDURES Excision of an eyeball enuclea
SURGICAL PROCEDURES Excision of an eyeball/enucleation
Indications include a blind, painful eye, a blind, cosmetically poor eye/intraocular neoplasm and, in cadavers, for use in corneal grafting. The operation The speculum is introduced between the lids and opened. The conjunctiva is picked up with toothed forceps and divided completely all round as near as possible to the cornea. Tenon’s capsule is entered and each of  the four rectus and two oblique muscle tendons is hooked up on a strabismus hook and divided close to the sclera. The speculum is now pressed backwards and the eyeball projects forwards. Blunt scissors, curved on the flat, are insinuated on the inner side of  the globe, and these are used to sever the optic nerve. The eyeball can now be drawn forwards with the forceps, and the oblique muscles, together with any other strands of  tissue that are still attaching the globe to the orbit, are divided. A swab, moistened with hot water and pressed into the orbit, will control the haemorrhage. If an orbital implant is inserted to give better eye movement, the muscles are sutured to the implant at the appropriate sites. The subconjunctival tissues and conjunctiva are closed in layers. Evisceration is preferred to excision in endo-ophthalmitis, minimising the risk of  orbital and intracranial spread with meningitis. The sclera is transfixed with a pointed knife a little behind the corneosclerotic junction, and the cornea is removed entirely by completing the encircling incision in the sclera. The contents of  the globe are then removed with a curette, care being exercised to remove all of  the uveal tract. At the end of  the operation the interior must appear perfectly white. A ball orbital implant made of  acrylic or hydroxyapatite may be placed within the orbit behind the sclera to improve the appearance when the artificial eye is fitted. SURGICAL PROCEDURES Excision of an eyeball/enucleation
Indications include a blind, painful eye, a blind, cosmetically poor eye/intraocular neoplasm and, in cadavers, for use in corneal grafting. The operation The speculum is introduced between the lids and opened. The conjunctiva is picked up with toothed forceps and divided completely all round as near as possible to the cornea. Tenon’s capsule is entered and each of  the four rectus and two oblique muscle tendons is hooked up on a strabismus hook and divided close to the sclera. The speculum is now pressed backwards and the eyeball projects forwards. Blunt scissors, curved on the flat, are insinuated on the inner side of  the globe, and these are used to sever the optic nerve. The eyeball can now be drawn forwards with the forceps, and the oblique muscles, together with any other strands of  tissue that are still attaching the globe to the orbit, are divided. A swab, moistened with hot water and pressed into the orbit, will control the haemorrhage. If an orbital implant is inserted to give better eye movement, the muscles are sutured to the implant at the appropriate sites. The subconjunctival tissues and conjunctiva are closed in layers. Evisceration is preferred to excision in endo-ophthalmitis, minimising the risk of  orbital and intracranial spread with meningitis. The sclera is transfixed with a pointed knife a little behind the corneosclerotic junction, and the cornea is removed entirely by completing the encircling incision in the sclera. The contents of  the globe are then removed with a curette, care being exercised to remove all of  the uveal tract. At the end of  the operation the interior must appear perfectly white. A ball orbital implant made of  acrylic or hydroxyapatite may be placed within the orbit behind the sclera to improve the appearance when the artificial eye is fitted.

SURGICAL PROCEDURES Excision of an eyeball enucleation
SURGICAL PROCEDURES Excision of an eyeball/enucleation
Indications include a blind, painful eye, a blind, cosmetically poor eye/intraocular neoplasm and, in cadavers, for use in corneal grafting. The operation The speculum is introduced between the lids and opened. The conjunctiva is picked up with toothed forceps and divided completely all round as near as possible to the cornea. Tenon’s capsule is entered and each of  the four rectus and two oblique muscle tendons is hooked up on a strabismus hook and divided close to the sclera. The speculum is now pressed backwards and the eyeball projects forwards. Blunt scissors, curved on the flat, are insinuated on the inner side of  the globe, and these are used to sever the optic nerve. The eyeball can now be drawn forwards with the forceps, and the oblique muscles, together with any other strands of  tissue that are still attaching the globe to the orbit, are divided. A swab, moistened with hot water and pressed into the orbit, will control the haemorrhage. If an orbital implant is inserted to give better eye movement, the muscles are sutured to the implant at the appropriate sites. The subconjunctival tissues and conjunctiva are closed in layers. Evisceration is preferred to excision in endo-ophthalmitis, minimising the risk of  orbital and intracranial spread with meningitis. The sclera is transfixed with a pointed knife a little behind the corneosclerotic junction, and the cornea is removed entirely by completing the encircling incision in the sclera. The contents of  the globe are then removed with a curette, care being exercised to remove all of  the uveal tract. At the end of  the operation the interior must appear perfectly white. A ball orbital implant made of  acrylic or hydroxyapatite may be placed within the orbit behind the sclera to improve the appearance when the artificial eye is fitted.

Subconjunctival haemorrhage
Subconjunctival haemorrhage
This presents as a bright red eye, often noticed incidentally with only minimal discomfort and normal vision. Causes include coughing, sneezing, minor trauma, hypertension and, rarely , a bleeding disorder. Subconjunctival haemorrhages are more common in those receiving antiplatelet or anticoagulation therapy . Reassurance and treatment of  the underlying cause are required. Most settle within a week, but can recur. Subconjunctival haemorrhage
This presents as a bright red eye, often noticed incidentally with only minimal discomfort and normal vision. Causes include coughing, sneezing, minor trauma, hypertension and, rarely , a bleeding disorder. Subconjunctival haemorrhages are more common in those receiving antiplatelet or anticoagulation therapy . Reassurance and treatment of  the underlying cause are required. Most settle within a week, but can recur. Subconjunctival haemorrhage
This presents as a bright red eye, often noticed incidentally with only minimal discomfort and normal vision. Causes include coughing, sneezing, minor trauma, hypertension and, rarely , a bleeding disorder. Subconjunctival haemorrhages are more common in those receiving antiplatelet or anticoagulation therapy . Reassurance and treatment of  the underlying cause are required. Most settle within a week, but can recur.

Swellings of the lacrimal system Lacrimal sac muco
Swellings of the lacrimal system Lacrimal sac mucocele
This occurs from obstruction of  the lacrimal duct beyond the sac and results in a fluctuant swelling that bulges out just below the medial canthus. It can become infected to give rise to a painful tense swelling (acute dacryocystitis). If  untreated, it may give rise to a fistula. Treatment is by performing a bypass operation between the lacrimal sac and the nose (a dacryo - cystorhinostomy). Watering of  the eye can also occur as a result of  eversion of  the lower lid (ectropion), which causes loss of contact between the lower punctum and the tear film, or from inturning lashes in entropion, and these must be distinguished from a mucocele. Lacrimal gland tumours These are swellings of  the lacrimal glands, which lie in the upper lateral aspect of the orbit. Eventually they lead to impairment of  ocular movements and displacement of  the globe forwards, downwards and inwards. Pathologically the tumours resemble parotid tumours and they can be pleomorphic adenomas with or without malignant change, carcinomas or mucoepidermoid tumours. Swellings of the lacrimal system Lacrimal sac mucocele
This occurs from obstruction of  the lacrimal duct beyond the sac and results in a fluctuant swelling that bulges out just below the medial canthus. It can become infected to give rise to a painful tense swelling (acute dacryocystitis). If  untreated, it may give rise to a fistula. Treatment is by performing a bypass operation between the lacrimal sac and the nose (a dacryo - cystorhinostomy). Watering of  the eye can also occur as a result of  eversion of  the lower lid (ectropion), which causes loss of contact between the lower punctum and the tear film, or from inturning lashes in entropion, and these must be distinguished from a mucocele. Lacrimal gland tumours These are swellings of  the lacrimal glands, which lie in the upper lateral aspect of the orbit. Eventually they lead to impairment of  ocular movements and displacement of  the globe forwards, downwards and inwards. Pathologically the tumours resemble parotid tumours and they can be pleomorphic adenomas with or without malignant change, carcinomas or mucoepidermoid tumours.

Swellings of the lacrimal system Lacrimal sac mucocele
Swellings of the lacrimal system Lacrimal sac mucocele
This occurs from obstruction of  the lacrimal duct beyond the sac and results in a fluctuant swelling that bulges out just below the medial canthus. It can become infected to give rise to a painful tense swelling (acute dacryocystitis). If  untreated, it may give rise to a fistula. Treatment is by performing a bypass operation between the lacrimal sac and the nose (a dacryo - cystorhinostomy). Watering of  the eye can also occur as a result of  eversion of  the lower lid (ectropion), which causes loss of contact between the lower punctum and the tear film, or from inturning lashes in entropion, and these must be distinguished from a mucocele. Lacrimal gland tumours These are swellings of  the lacrimal glands, which lie in the upper lateral aspect of the orbit. Eventually they lead to impairment of  ocular movements and displacement of  the globe forwards, downwards and inwards. Pathologically the tumours resemble parotid tumours and they can be pleomorphic adenomas with or without malignant change, carcinomas or mucoepidermoid tumours.

Swellings of the lids Meibomian cysts (chalazion)
Swellings of the lids Meibomian cysts (chalazion)
These are the most common lid swellings ( Figure 49.4 ). A meibomian cyst is a chronic granulomatous inflammation of  a meibomian gland. It may occur on either upper or lower lids and presents as a smooth, painless swelling. It can be felt by rolling the cyst on the tarsal plate. It can be distinguished from a stye (hordeolum), which is an infection of  a hair follicle and is usually painful. Persistent meibomian cysts that do not resolve with conservative treatment (hot compresses) are treated by incision and curettage from the conjunctival surface. Styes are treated by antibiotics and local heat. Basal cell carcinoma (rodent ulcer) This is the most common malignant tumour of  the eyelids ( Figure 49.5 ). Basal cell carcinomas may be locally invasive but do not tend to metastasise. They are more common on the lower lids, often start as a small pimple that ulcerates and has raised edges (‘rodent ulcer’) and are usually easily excised in the early stages. Histological confirmation that the excision is complete is required. More extensive lesions may require specialist techniques such as Mohs’ micrographic surgical excision controlled by frozen section. Local radiotherapy or cryotherapy can be carried out; however, recurrence is more common, more aggressive and more di ffi cult to detect. Frederic E Mohs , 1910–2002, developed the technique of  micrographic surgical excision while a medical student at University of  Wisconsin, USA. Jacob Antonius Moll , 1832–1913, ophthalmologist of  The Hague, The Netherlands. Eduard Zeis , 1807–1868, Professor of  Surgery , Marburg (1844–1850), who later worked at Dresden, Germany , described these glands in 1835. Basal cell carcinomas /uni25CF /uni25CF /uni25CF
Figure 49.4
Meibomian cyst (courtesy of Mr D Spalton, FRCS).
Figure 49.5
Rodent ulcers (courtesy of Mr J Beare, FRCS).
Basal cell carcinomas are the most common malignant eyelid
tumour
Treatment is by wide local excision with careful
histopathological margin control
All unusual eyelid lesions (especially in the elderly) should be
biopsied
Swellings of the lids Meibomian cysts (chalazion)
These are the most common lid swellings ( Figure 49.4 ). A meibomian cyst is a chronic granulomatous inflammation of  a meibomian gland. It may occur on either upper or lower lids and presents as a smooth, painless swelling. It can be felt by rolling the cyst on the tarsal plate. It can be distinguished from a stye (hordeolum), which is an infection of  a hair follicle and is usually painful. Persistent meibomian cysts that do not resolve with conservative treatment (hot compresses) are treated by incision and curettage from the conjunctival surface. Styes are treated by antibiotics and local heat. Basal cell carcinoma (rodent ulcer) This is the most common malignant tumour of  the eyelids ( Figure 49.5 ). Basal cell carcinomas may be locally invasive but do not tend to metastasise. They are more common on the lower lids, often start as a small pimple that ulcerates and has raised edges (‘rodent ulcer’) and are usually easily excised in the early stages. Histological confirmation that the excision is complete is required. More extensive lesions may require specialist techniques such as Mohs’ micrographic surgical excision controlled by frozen section. Local radiotherapy or cryotherapy can be carried out; however, recurrence is more common, more aggressive and more di ffi cult to detect. Frederic E Mohs , 1910–2002, developed the technique of  micrographic surgical excision while a medical student at University of  Wisconsin, USA. Jacob Antonius Moll , 1832–1913, ophthalmologist of  The Hague, The Netherlands. Eduard Zeis , 1807–1868, Professor of  Surgery , Marburg (1844–1850), who later worked at Dresden, Germany , described these glands in 1835. Basal cell carcinomas /uni25CF /uni25CF /uni25CF
Figure 49.4
Meibomian cyst (courtesy of Mr D Spalton, FRCS).
Figure 49.5
Rodent ulcers (courtesy of Mr J Beare, FRCS).
Basal cell carcinomas are the most common malignant eyelid
tumour
Treatment is by wide local excision with careful
histopathological margin control
All unusual eyelid lesions (especially in the elderly) should be
biopsied
Swellings of the lids Meibomian cysts (chalazion)
These are the most common lid swellings ( Figure 49.4 ). A meibomian cyst is a chronic granulomatous inflammation of  a meibomian gland. It may occur on either upper or lower lids and presents as a smooth, painless swelling. It can be felt by rolling the cyst on the tarsal plate. It can be distinguished from a stye (hordeolum), which is an infection of  a hair follicle and is usually painful. Persistent meibomian cysts that do not resolve with conservative treatment (hot compresses) are treated by incision and curettage from the conjunctival surface. Styes are treated by antibiotics and local heat. Basal cell carcinoma (rodent ulcer) This is the most common malignant tumour of  the eyelids ( Figure 49.5 ). Basal cell carcinomas may be locally invasive but do not tend to metastasise. They are more common on the lower lids, often start as a small pimple that ulcerates and has raised edges (‘rodent ulcer’) and are usually easily excised in the early stages. Histological confirmation that the excision is complete is required. More extensive lesions may require specialist techniques such as Mohs’ micrographic surgical excision controlled by frozen section. Local radiotherapy or cryotherapy can be carried out; however, recurrence is more common, more aggressive and more di ffi cult to detect. Frederic E Mohs , 1910–2002, developed the technique of  micrographic surgical excision while a medical student at University of  Wisconsin, USA. Jacob Antonius Moll , 1832–1913, ophthalmologist of  The Hague, The Netherlands. Eduard Zeis , 1807–1868, Professor of  Surgery , Marburg (1844–1850), who later worked at Dresden, Germany , described these glands in 1835. Basal cell carcinomas /uni25CF /uni25CF /uni25CF
Figure 49.4
Meibomian cyst (courtesy of Mr D Spalton, FRCS).
Figure 49.5
Rodent ulcers (courtesy of Mr J Beare, FRCS).
Basal cell carcinomas are the most common malignant eyelid
tumour
Treatment is by wide local excision with careful
histopathological margin control
All unusual eyelid lesions (especially in the elderly) should be
biopsied

The globe
The globe
The cornea is the 12-mm-diameter window of  the eye, 550 /uni00A0 µm thick centrally on average; its clarity is due to the regular Heinrich Meibom (Meibomius) , 1638–1700, Professor of  Medicine, History and Poetry , Helmstadt, Germany , described these glands in 1666. Johannes Peter Müller , 1801–1858, Professor of  Anatomy and Physiology , Berlin, Germany . Johan Friedrich Horner , 1831–1886, Professor of  Ophthalmology , Zurich, Switzerland, described this syndrome in 1869. arrangement of  collagen bundles and relative dehydration. It merges into the sclera at the corneoscleral junction (the limbus), the insertion of  the bulbar conjunctiva. The sclera, which is 1 /uni00A0 mm thick, constitutes four-fifths of  the wall of  the eye and gives attachment to the extraocular muscles ( Figure 49.1 ). It is perforated by the long and short posterior ciliary arteries and the vortex veins and is contiguous with the optic nerve sheath. -
The value of special investigations
•
When specialist referral is appropriate
•
Recent advances in ocular surgery
•
Choroid Sclera
Superior
Lens
Retina
re
ctus
Conjunctiva
Canal of
Schlem
m
Central
re
tinal
Cornea
artery
Optic
nerve
Iris
Macula
Vascular
choroid
Ciliary body
Inferior
Vitreous
re
ctus
Uvea
humour
Figure 49.1
Anatomy of the eye.
Photoreceptor cells in the outer retina sense light and send impulses to retinal ganglion cells in the inner retina via bipolar cells. The retinal pigment epithelium underlies the photo- receptors and is responsible for reprocessing of  photopigments. The optic nerve conveys the axons of  retinal ganglion cells from the eye to the brain. The most high-resolution part of  the retina – the macula – lies at the posterior pole within the vascular arcade. The biconvex lens and capsule are suspended by the lens zonules, over 300 tiny fibres attached to the ciliary muscle. Aqueous humour arises from the ciliary processes, hydrates the vitreous gel, passes through the pupil into the anterior chamber between the iris and the cornea and then drains out through the trabecular meshwork into Schlemm’s canal in the drainage angle and from there to the episcleral venous circulation. The balance between production and drainage of  aqueous humour determines the intraocular pressure, which in most normal eyes is regulated at a level of 10–21 /uni00A0 mmHg. The inner retina is supplied by the central retinal artery and drained by the central retinal vein. The globe
The cornea is the 12-mm-diameter window of  the eye, 550 /uni00A0 µm thick centrally on average; its clarity is due to the regular Heinrich Meibom (Meibomius) , 1638–1700, Professor of  Medicine, History and Poetry , Helmstadt, Germany , described these glands in 1666. Johannes Peter Müller , 1801–1858, Professor of  Anatomy and Physiology , Berlin, Germany . Johan Friedrich Horner , 1831–1886, Professor of  Ophthalmology , Zurich, Switzerland, described this syndrome in 1869. arrangement of  collagen bundles and relative dehydration. It merges into the sclera at the corneoscleral junction (the limbus), the insertion of  the bulbar conjunctiva. The sclera, which is 1 /uni00A0 mm thick, constitutes four-fifths of  the wall of  the eye and gives attachment to the extraocular muscles ( Figure 49.1 ). It is perforated by the long and short posterior ciliary arteries and the vortex veins and is contiguous with the optic nerve sheath. -
The value of special investigations
•
When specialist referral is appropriate
•
Recent advances in ocular surgery
•
Choroid Sclera
Superior
Lens
Retina
re
ctus
Conjunctiva
Canal of
Schlem
m
Central
re
tinal
Cornea
artery
Optic
nerve
Iris
Macula
Vascular
choroid
Ciliary body
Inferior
Vitreous
re
ctus
Uvea
humour
Figure 49.1
Anatomy of the eye.
Photoreceptor cells in the outer retina sense light and send impulses to retinal ganglion cells in the inner retina via bipolar cells. The retinal pigment epithelium underlies the photo- receptors and is responsible for reprocessing of  photopigments. The optic nerve conveys the axons of  retinal ganglion cells from the eye to the brain. The most high-resolution part of  the retina – the macula – lies at the posterior pole within the vascular arcade. The biconvex lens and capsule are suspended by the lens zonules, over 300 tiny fibres attached to the ciliary muscle. Aqueous humour arises from the ciliary processes, hydrates the vitreous gel, passes through the pupil into the anterior chamber between the iris and the cornea and then drains out through the trabecular meshwork into Schlemm’s canal in the drainage angle and from there to the episcleral venous circulation. The balance between production and drainage of  aqueous humour determines the intraocular pressure, which in most normal eyes is regulated at a level of 10–21 /uni00A0 mmHg. The inner retina is supplied by the central retinal artery and drained by the central retinal vein. The globe
The cornea is the 12-mm-diameter window of  the eye, 550 /uni00A0 µm thick centrally on average; its clarity is due to the regular Heinrich Meibom (Meibomius) , 1638–1700, Professor of  Medicine, History and Poetry , Helmstadt, Germany , described these glands in 1666. Johannes Peter Müller , 1801–1858, Professor of  Anatomy and Physiology , Berlin, Germany . Johan Friedrich Horner , 1831–1886, Professor of  Ophthalmology , Zurich, Switzerland, described this syndrome in 1869. arrangement of  collagen bundles and relative dehydration. It merges into the sclera at the corneoscleral junction (the limbus), the insertion of  the bulbar conjunctiva. The sclera, which is 1 /uni00A0 mm thick, constitutes four-fifths of  the wall of  the eye and gives attachment to the extraocular muscles ( Figure 49.1 ). It is perforated by the long and short posterior ciliary arteries and the vortex veins and is contiguous with the optic nerve sheath. -
The value of special investigations
•
When specialist referral is appropriate
•
Recent advances in ocular surgery
•
Choroid Sclera
Superior
Lens
Retina
re
ctus
Conjunctiva
Canal of
Schlem
m
Central
re
tinal
Cornea
artery
Optic
nerve
Iris
Macula
Vascular
choroid
Ciliary body
Inferior
Vitreous
re
ctus
Uvea
humour
Figure 49.1
Anatomy of the eye.
Photoreceptor cells in the outer retina sense light and send impulses to retinal ganglion cells in the inner retina via bipolar cells. The retinal pigment epithelium underlies the photo- receptors and is responsible for reprocessing of  photopigments. The optic nerve conveys the axons of  retinal ganglion cells from the eye to the brain. The most high-resolution part of  the retina – the macula – lies at the posterior pole within the vascular arcade. The biconvex lens and capsule are suspended by the lens zonules, over 300 tiny fibres attached to the ciliary muscle. Aqueous humour arises from the ciliary processes, hydrates the vitreous gel, passes through the pupil into the anterior chamber between the iris and the cornea and then drains out through the trabecular meshwork into Schlemm’s canal in the drainage angle and from there to the episcleral venous circulation. The balance between production and drainage of  aqueous humour determines the intraocular pressure, which in most normal eyes is regulated at a level of 10–21 /uni00A0 mmHg. The inner retina is supplied by the central retinal artery and drained by the central retinal vein.

Treatment
Treatment
Treatment is directed to the cause of  the lesion, taking care to prevent exposure of  the eye, diplopia or visual impairment from optic nerve compression. Treatment
Treatment is directed to the cause of  the lesion, taking care to prevent exposure of  the eye, diplopia or visual impairment from optic nerve compression. Treatment
Treatment is directed to the cause of  the lesion, taking care to prevent exposure of  the eye, diplopia or visual impairment from optic nerve compression.

Uveitis
Uveitis
This can be anterior (iritis) or, more rarely , posterior. In anterior uveitis, the pupil is sometimes small and/or irregular owing to formation of  posterior synechiae (adhesions between the iris and the lens). There is often circumcorneal injection and there may be keratic precipitates present on the posterior surface of  the cornea. Pain, photophobia and some visual loss are usually present. Posterior uveitis can present with a white eye and blurred vision. It usually takes a chronic course. Granulomatous diseases, Behçet’s disease, Reiter’s syndrome, toxoplasmosis and cytomegalovirus infection should be excluded. Topical systemic steroids and, sometimes, immuno - suppressive drugs are useful in treating these conditions; management should be under the care of  an ophthalmologist.
Figure 49.30
Dendritic staining caused by herpes keratitis.
Episcleritis or inflammation of the episcleral tissue often occurs as an idiopathic condition ( Figure 49.31 ). Scleritis is a less common, more serious, condition in which the deeper sclera is involved. There is often an associated uveitis and severe pain. Thinning of  the sclera may result. Systemic non-steroidal anti-inflammatory drugs or steroids/other immunomodula tory agents may be required to treat the condition adequately . Approximately half  of  patients with scleritis have an under lying systemic disorder. Scleritis is often associated with severe rheumatoid con ditions . The presence of scleritis suggests that there is active systemic disease and this requires systemic work-up, including renal function tests. Uveitis
This can be anterior (iritis) or, more rarely , posterior. In anterior uveitis, the pupil is sometimes small and/or irregular owing to formation of  posterior synechiae (adhesions between the iris and the lens). There is often circumcorneal injection and there may be keratic precipitates present on the posterior surface of  the cornea. Pain, photophobia and some visual loss are usually present. Posterior uveitis can present with a white eye and blurred vision. It usually takes a chronic course. Granulomatous diseases, Behçet’s disease, Reiter’s syndrome, toxoplasmosis and cytomegalovirus infection should be excluded. Topical systemic steroids and, sometimes, immuno - suppressive drugs are useful in treating these conditions; management should be under the care of  an ophthalmologist.
Figure 49.30
Dendritic staining caused by herpes keratitis.
Episcleritis or inflammation of the episcleral tissue often occurs as an idiopathic condition ( Figure 49.31 ). Scleritis is a less common, more serious, condition in which the deeper sclera is involved. There is often an associated uveitis and severe pain. Thinning of  the sclera may result. Systemic non-steroidal anti-inflammatory drugs or steroids/other immunomodula tory agents may be required to treat the condition adequately . Approximately half  of  patients with scleritis have an under lying systemic disorder. Scleritis is often associated with severe rheumatoid con ditions . The presence of scleritis suggests that there is active systemic disease and this requires systemic work-up, including renal function tests. Uveitis
This can be anterior (iritis) or, more rarely , posterior. In anterior uveitis, the pupil is sometimes small and/or irregular owing to formation of  posterior synechiae (adhesions between the iris and the lens). There is often circumcorneal injection and there may be keratic precipitates present on the posterior surface of  the cornea. Pain, photophobia and some visual loss are usually present. Posterior uveitis can present with a white eye and blurred vision. It usually takes a chronic course. Granulomatous diseases, Behçet’s disease, Reiter’s syndrome, toxoplasmosis and cytomegalovirus infection should be excluded. Topical systemic steroids and, sometimes, immuno - suppressive drugs are useful in treating these conditions; management should be under the care of  an ophthalmologist.
Figure 49.30
Dendritic staining caused by herpes keratitis.
Episcleritis or inflammation of the episcleral tissue often occurs as an idiopathic condition ( Figure 49.31 ). Scleritis is a less common, more serious, condition in which the deeper sclera is involved. There is often an associated uveitis and severe pain. Thinning of  the sclera may result. Systemic non-steroidal anti-inflammatory drugs or steroids/other immunomodula tory agents may be required to treat the condition adequately . Approximately half  of  patients with scleritis have an under lying systemic disorder. Scleritis is often associated with severe rheumatoid con ditions . The presence of scleritis suggests that there is active systemic disease and this requires systemic work-up, including renal function tests.