1. BSS solution - composition and concentrations
2. Iris bombe
3. Festooned pupil
4. PMMA - full form and use
5. Evisceration vs enucleation vs exenteration
6. Endophthalmitis and panophthalmitis - marrow-style treatment regimen
7. Chalazion
8. Ectropion and entropion - definitions and clinical features
9. Types of intraocular lenses (IOLs), with diagrams
10. Lacrimal drainage obstruction - types and anatomical sites

• Iris bombe results from posterior synechiae causing pupillary block and peripheral iris bowing forward.
• Festooned pupil is an irregular pupil due to localized posterior synechiae.
• PMMA means polymethyl methacrylate, a rigid IOL material.
• Eye-removal procedures differ by tissue removed: evisceration removes intraocular contents, enucleation removes the globe, and exenteration removes globe plus orbital contents.
• Lacrimal obstruction can occur at the punctum, canaliculi, common canaliculus, lacrimal sac, or nasolacrimal duct.

1. BSS, iris bombe, and festooned pupil
2. Eye-removal procedures
3. Endophthalmitis and panophthalmitis regimen
4. Chalazion, ectropion, and entropion
5. IOLs and lacrimal obstruction

1. BSS solution: contents and concentrations

• pH: about 7.5
• Osmolality: about 300 mOsm/kg
• Purpose: maintains intraocular osmotic balance and supplies ions needed for corneal endothelial function.

BSS Plus

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2. Iris bombe

Mechanism

1. Posterior synechiae form all around the pupil, called seclusio pupillae.
2. Aqueous humor cannot pass from posterior chamber to anterior chamber.
3. Pressure builds behind the iris.
4. Peripheral iris bows forward in a dome-shaped configuration.
5. The iridocorneal angle closes, causing secondary angle-closure glaucoma.

Normal:             Iris bombe:

Cornea              Cornea
  |                   |
  |     iris          |   iris bows forward
  |------/            |-----( 
  |                   |       ↑
Angle open         Angle closed

• Shallow peripheral anterior chamber
• Raised IOP
• Mid-dilated or irregular pupil
• Posterior synechiae
• Peripheral anterior synechiae may develop

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3. Festooned pupil

Normal pupil:       Festooned pupil:

     ○                    ~○~
                         Irregular margin

• Festooned pupil: localized posterior synechiae causing irregular pupil.
• Iris bombe: complete 360-degree posterior synechiae causing pupillary block and forward iris bowing.

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4. Full form of PMMA

• Rigid posterior chamber IOLs
• Older anterior chamber IOLs
• Some orbital implants and ocular prostheses

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5. Differentiate evisceration, enucleation, and exenteration

Definitions

• Evisceration: removal of the contents of the globe while retaining the scleral shell and extraocular muscles.
• Enucleation: surgical removal of the entire globe, after dividing the optic nerve and extraocular muscles.
• Exenteration: removal of the orbital contents. In radical exenteration, eyelids and orbital soft tissue are removed. Orbital bony walls are usually preserved unless tumor invasion requires their removal.

Never do evisceration if retinoblastoma, melanoma, or another intraocular malignancy is suspected.

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6. Regimen of endophthalmitis and panophthalmitis

A. Acute bacterial endophthalmitis

Immediate management

1. Urgent vitreous tap or biopsy
   • Send for Gram stain, KOH smear if indicated, culture and sensitivity.
2. Empirical intravitreal antibiotics
   • Vancomycin 1 mg/0.1 mL intravitreal
     • Coverage: Gram-positive organisms, including staphylococci.
   • Ceftazidime 2.25 mg/0.1 mL intravitreal
     • Coverage: Gram-negative organisms.
   If ceftazidime cannot be used:
   • Amikacin 0.4 mg/0.1 mL intravitreal may be used, though it has retinal toxicity risk.

1. Topical treatment
   • Fortified topical antibiotics according to local protocol
   • Cycloplegic, for example atropine 1% eye drops
   • Topical corticosteroid is generally added after antimicrobial therapy has been started, under specialist direction.
2. Systemic antibiotics
   • Particularly important in endogenous endophthalmitis, open-globe trauma, scleral involvement, or severe infection.
   • Choice should be guided by suspected source, culture, renal function, and local resistance pattern.
3. Pars plana vitrectomy (PPV)
   • Consider urgently for severe disease, dense vitreous exudates, retinal detachment, worsening infection, or very poor vision.
   • Classic EVS approach: immediate PPV is particularly indicated where presenting vision is only light perception. In modern practice, clinicians may operate earlier based on severity.
4. Repeat intravitreal antibiotic injection
   • Consider after 48-72 hours if pain, hypopyon, vitritis, or vision worsens, or culture indicates need for alternative therapy.

If fungal endophthalmitis is suspected

• Intravitreal amphotericin B: 5-10 micrograms/0.1 mL
  or
• Intravitreal voriconazole: 100 micrograms/0.1 mL
• Add systemic antifungal therapy and investigate for systemic candidemia or another source.
• Vitrectomy is often needed.

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B. Panophthalmitis

Regimen

1. Admit the patient urgently.
2. Obtain vitreous/aqueous sample, blood cultures if systemic source is possible, and culture any discharge.
3. Start intravitreal antibiotics:
   • Vancomycin 1 mg/0.1 mL
   • Ceftazidime 2.25 mg/0.1 mL
4. Start systemic broad-spectrum intravenous antibiotics, tailored to source, culture results, and local protocol.
5. Intensive topical antibiotics and cycloplegia.
6. Perform imaging if orbital extension is suspected.
7. Consider urgent vitreous surgery if the globe is salvageable.
8. If there is uncontrolled infection, corneal/scleral necrosis, a painful blind eye, or risk of spread, evisceration or enucleation may be required. Enucleation is preferred if intraocular tumor is a possibility.

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7. Chalazion

Clinical features

• Painless, slowly growing eyelid swelling
• Firm, localized nodule within the tarsal plate
• Usually away from the lid margin
• Overlying skin is mobile
• May cause astigmatism, ptosis, or blurred vision if large
• May be associated with blepharitis, acne rosacea, or meibomian gland dysfunction

Treatment

1. Warm compresses and lid massage
2. Lid hygiene and treatment of blepharitis
3. Intralesional triamcinolone in selected cases
4. Incision and curettage for persistent, large, or cosmetically concerning chalazion
5. Biopsy a recurrent chalazion in the same site, especially in an older adult, to exclude sebaceous gland carcinoma.

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8. Ectropion and entropion with clinical features

Ectropion

Normal lower lid:       Ectropion:

Eye surface             Eye surface
   ______                  ______
  /      \                /      \
  \______/                \______/
    lid                     lid turns outward
                              \__

Types of ectropion

• Involutional or senile
• Cicatricial
• Paralytic, such as facial nerve palsy
• Mechanical
• Congenital

Clinical features

• Eversion of lid margin
• Punctal eversion causing epiphora
• Exposure conjunctivitis
• Redness and irritation
• Foreign-body sensation
• Dry eye
• Exposure keratopathy or corneal ulcer in severe cases
• Mucus discharge and chronic conjunctivitis

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Entropion

Normal lower lid:       Entropion:

Eye surface             Eye surface
   ______                  ______
  /      \                /      \
  \______/                \______/
    lid                     lid turns inward
                          __/
                         lashes touch cornea

Types of entropion

• Involutional or senile
• Cicatricial
• Spastic
• Congenital

Clinical features

• Inturned lid margin
• Trichiasis: eyelashes rub the cornea
• Foreign-body sensation
• Watering
• Pain and photophobia
• Conjunctival injection
• Punctate epithelial erosions
• Corneal abrasion, ulceration, scarring, and reduced vision in severe untreated cases

Key difference

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9. Types of IOL with diagram

A. Based on site of fixation

1. Posterior chamber IOL, PCIOL

Cornea     Iris       IOL inside capsular bag
  |         |                 ___
  |         |                /   \
  |        ( )              | IOL |
  |                          \___/

• Can be placed:
  • In-the-bag
  • Sulcus-fixated, when capsular support is partly deficient
• Usually foldable.

2. Anterior chamber IOL, ACIOL

Cornea
  |
 [ IOL ]     ← anterior chamber
  |
 Iris

• Used when posterior capsular support is absent.
• Risks: endothelial cell loss, corneal decompensation, raised IOP, uveitis.

3. Iris-fixated or iris-claw IOL

Cornea
  |
  \ IOL /    ← enclavated to iris
   Iris

4. Scleral-fixated IOL, SFIOL

Sclera |--------------------| Sclera
             \  IOL  /
              \____/
        Haptics fixed to sclera

5. Iris-sutured posterior chamber IOL

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B. Based on material

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C. Based on optical design

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10. Types of lacrimal block and their anatomical sites

Punctum → Canaliculus → Common canaliculus
       → Lacrimal sac → Nasolacrimal duct
       → Valve of Hasner → Inferior meatus of nose

A. According to anatomical site

B. According to cause

1. Congenital nasolacrimal duct obstruction

• Most commonly due to failure of canalization at the valve of Hasner.
• Presents with epiphora and sticky discharge in infancy.

2. Acquired primary nasolacrimal duct obstruction

• Idiopathic inflammatory fibrosis of the nasolacrimal duct.
• Common in middle-aged or older women.

3. Secondary acquired lacrimal obstruction

• Trauma
• Chronic infection
• Canaliculitis
• Eyelid disease
• Conjunctival cicatrization, for example Stevens-Johnson syndrome or ocular cicatricial pemphigoid
• Tumor
• Nasal or paranasal sinus disease
• Radiotherapy
• Drug-related canalicular stenosis, for example topical anti-glaucoma drugs or systemic chemotherapy agents

C. Clinical localization by syringing

Ophthalmology: 5-Mark Exam-Oriented Answers

1. Balanced Salt Solution (BSS): contents with concentrations

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2. Iris bombe

Pathogenesis

1. Posterior synechiae join around the entire pupillary margin.
2. Aqueous humor cannot pass from posterior chamber to anterior chamber.
3. Pressure rises in the posterior chamber.
4. Peripheral iris bulges forward.
5. The anterior chamber angle closes, causing secondary angle-closure glaucoma.

Clinical features

• Shallow peripheral anterior chamber
• Convex forward bowing of iris
• Raised IOP
• Seclusio pupillae
• Irregular, fixed pupil
• Pain, redness, and blurred vision may occur

Treatment

• Topical steroids and cycloplegics for uveitis
• Control IOP
• Laser peripheral iridotomy or surgical iridectomy

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3. Festooned pupil

Causes

• Most commonly anterior uveitis or iridocyclitis
• Trauma
• Postoperative inflammation

Features

• Irregular pupillary margin
• Pupil does not dilate uniformly after mydriatic
• Localized adhesions of iris to lens
• May be associated with cells, flare, keratic precipitates, and other signs of anterior uveitis

Importance

• Festooned pupil: localized posterior synechiae
• Iris bombe: 360-degree posterior synechiae causing pupillary block

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4. PMMA: full form

Uses in ophthalmology

• Rigid intraocular lenses
• Some anterior chamber IOLs
• Ocular prostheses
• Orbital implants

Properties

• Rigid, non-foldable material
• Biocompatible and optically clear
• Requires a larger incision for IOL insertion compared with foldable acrylic IOLs

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5. Evisceration, enucleation, and exenteration

Definitions

• Evisceration: removal of cornea and intraocular contents, leaving scleral shell behind.
• Enucleation: removal of the complete eyeball after division of extraocular muscles and optic nerve.
• Exenteration: removal of globe, extraocular muscles, orbital fat, lacrimal gland, and sometimes eyelids.

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6. Regimen of endophthalmitis and panophthalmitis

A. Acute bacterial endophthalmitis

Management

1. Urgent vitreous tap or vitreous biopsy
   • Send for Gram stain, KOH mount, culture, and sensitivity.
2. Intravitreal antibiotics
   • Vancomycin 1 mg/0.1 mL for Gram-positive organisms
   • Ceftazidime 2.25 mg/0.1 mL for Gram-negative organisms
   Alternative to ceftazidime:
   • Amikacin 0.4 mg/0.1 mL intravitreal
3. Topical therapy
   • Intensive topical antibiotics
   • Atropine 1% as cycloplegic
   • Topical steroid after starting antimicrobial therapy
4. Systemic antibiotics
   • Especially in endogenous endophthalmitis, trauma, or severe cases
   • Modify according to culture and sensitivity
5. Pars plana vitrectomy
   • Indicated in severe infection, dense vitritis, retinal detachment, worsening infection, or visual acuity of light perception only.
6. Repeat intravitreal injection
   • Consider after 48-72 hours if response is poor.

Fungal endophthalmitis

• Intravitreal amphotericin B: 5-10 micrograms/0.1 mL
• Or intravitreal voriconazole: 100 micrograms/0.1 mL
• Add systemic antifungal therapy and consider vitrectomy.

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B. Panophthalmitis

Management

• Admit urgently
• Aqueous/vitreous sample and blood culture where indicated
• Intravitreal vancomycin plus ceftazidime
• Intensive topical antibiotics and cycloplegics
• Systemic broad-spectrum IV antibiotics
• Treat orbital cellulitis if present
• Vitrectomy if eye is potentially salvageable
• Evisceration or enucleation in a painful blind eye, scleral necrosis, uncontrolled infection, or risk of spread

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7. Chalazion

Etiology

• Meibomian gland blockage
• Chronic blepharitis
• Acne rosacea
• Meibomian gland dysfunction

Clinical features

• Painless, firm, localized swelling in eyelid
• Usually situated away from lid margin
• Skin over lesion is freely movable
• May be visible from conjunctival side
• Large chalazion can cause astigmatism and blurred vision
• Recurrent lesion in elderly may indicate sebaceous gland carcinoma

Treatment

• Warm compresses
• Lid hygiene and massage
• Treatment of associated blepharitis
• Intralesional triamcinolone in selected cases
• Incision and curettage for persistent lesions
• Biopsy recurrent chalazion at same site, especially in elderly patients

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8. Ectropion and entropion with clinical features

A. Ectropion

Types

• Involutional or senile
• Cicatricial
• Paralytic
• Mechanical
• Congenital

Clinical features

• Outwardly everted lower lid
• Punctal eversion
• Epiphora due to defective tear drainage
• Dryness and foreign-body sensation
• Conjunctival congestion and keratinization
• Exposure keratopathy
• Corneal ulcer in severe cases

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B. Entropion

Types

• Involutional or senile
• Cicatricial
• Spastic
• Congenital

Clinical features

• Inturned lid margin
• Trichiasis
• Watering and photophobia
• Foreign-body sensation and pain
• Conjunctival congestion
• Corneal epithelial erosions
• Corneal ulcer, scarring, and reduced vision in severe cases

Difference

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9. Types of IOL with diagram

A. According to position/fixation

1. Posterior chamber IOL, PCIOL

Cornea     Iris      Capsular bag
  |         |          ______
  |        ( )        / IOL  \
  |                   \______/

2. Anterior chamber IOL, ACIOL

Cornea
  |
 [ IOL ]   ← anterior chamber
  |
 Iris

3. Iris-claw IOL

Cornea
  |
 \ IOL /   ← fixed to iris
  (iris)

4. Scleral-fixated IOL, SFIOL

Sclera  |----\ IOL /----|  Sclera
         haptic fixation

5. Iris-sutured IOL

B. According to material

• PMMA IOL
• Hydrophobic acrylic IOL
• Hydrophilic acrylic IOL
• Silicone IOL

C. According to optical design

• Monofocal IOL
• Multifocal IOL
• Toric IOL
• Extended depth-of-focus IOL
• Accommodative IOL
• Aspheric IOL

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10. Types of lacrimal block and anatomical sites

Lacrimal drainage pathway

Punctum → Canaliculus → Common canaliculus
→ Lacrimal sac → Nasolacrimal duct
→ Valve of Hasner → Inferior meatus of nose

A. According to anatomical site

B. According to etiology

1. Congenital block

• Usually failure of canalization of valve of Hasner
• Presents with watering and discharge in infancy

2. Acquired primary nasolacrimal duct obstruction

• Idiopathic inflammatory fibrosis of nasolacrimal duct
• Common in middle-aged women

3. Secondary acquired lacrimal obstruction

• Trauma
• Infection
• Chronic dacryocystitis
• Tumor
• Nasal and paranasal sinus disease
• Conjunctival cicatrizing disorders
• Radiotherapy
• Drug-induced canalicular stenosis

Syringing findings