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Oftalmologia > BCSC Fundamentals > Flashcards

BCSC Fundamentals Flashcards

1
Q

What is the volume of each adult orbit?

A

30 cc

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2
Q

What are the seven bones of the bony orbit?

A

Frontal, Zygomatic, Maxilla, Ethmoid, Sphenoid, Lacrimal, Palatine

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3
Q

Which bones form the orbital roof?

A

Frontal bone and lesser wing of the sphenoid

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4
Q

Which bones form the medial wall of the orbit?

A

1) Frontal process of maxilla, 2) Lacrimal bone, 3) orbital plate of ethmoid, 4) Leser wing of sphenoid

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5
Q

Which bones form the orbital floor?

A

1) Maxilla, 2) Palatine, 3) Orbital plate of zygomatic

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6
Q

Which bones form the lateral orbital wall?

A

1) Zygomatic and 2) Greater wing of the sphenoid

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7
Q

What does the Whitnall tubercle indicate?

A

The site of attachment of 1) check ligament of LR muscle, 2) suspensory ligament of eyeball, 3) lateral palpebral ligament, 4) levator aponeurosis, 5) Whitnall ligament

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8
Q

What are the orbital foramina?

A

1) optic, 2) supraorbital, 3) anterior ethmoidal, 4) posterior ethmoidal, 5) zygomatic

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9
Q

Which structures are above the annulus of Zinn in the Superior Orbital Fissure?

A

lacrimal nerve of V1, frontal nerve of V1, CN IV, sup ophthalmic vein

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10
Q

Which structures are within the annulus of Zinn?

A

sup and inf divisions of CN III, nasociliary branch of V1, sympathetic roots of ciliary ganglion, CN VI

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11
Q

Which structures pass through the Inferior Orbital Fissure?

A

Infraorbital and zygomatic branches of V2, an orbital nerve from pterygopalatine ganglion, and inferior ophthalmic vein

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12
Q

What are the four sinuses?

A

Frontal, ethmoidal, sphenoid, maxillary

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13
Q

Which 3 roots does the ciliary ganglion receive?

A

1) long sensory root from nasociliary branch of V1, 2) short motor root from inf division of CN III, 3) sympathetic root from plexus around ICA

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14
Q

What is the 7th extraocular muscle?

A

Levator palpebrae superioris

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15
Q

List the rectus muscles in order of increasing distance of insertion from the limbus

A

1) MR (5.5), 2) IR (6.5), 3) LR (6.9), 4) SR (7.7)

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16
Q

What is the name for the curve passing through the rectus muscle insertions?

A

Spiral of Tillaux

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17
Q

Where does the superior oblique insert?

A

onto the sclera superiorly, under the insertion of the SR, after passing through the trochlea in the superior nasal orbital rim

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18
Q

What does the annulus of Zinn consist of?

A

The superior and inferior orbital tendons. It is the origin of the four rectus muscles

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19
Q

Where is the origin of the levator muscle?

A

lesser wing of the sphenoid, at the apex of the orbit, just superior to the annulus of Zinn

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20
Q

Where is the origin of the SO muscle?

A

periosteum of the body of the sphenoid bone, above and medial to the optic foramen

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21
Q

Where does the IO muscle originate?

A

from a shallow depression in the orbital plate of the maxillary bone, anteriorly

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22
Q

Which arteries supply the EOMs?

A

Inf and sup muscular branches of ophthalmic artery, lacrimal artery, and infraorbital artery

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23
Q

Which EOMs are innervated by the superior division of CN III?

A

levator and SR

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24
Q

Which EOMs are innervated by the inferior division of CN III?

A

MR, IR, IO

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25
Q

What type of fibers make up the EOMs?

A

both fast twitch and slow twitch fibers

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26
Q

What is the ratio of nerve fibers to muscle fibers in the EOMs?

A

1:3 (compared to 1:50 in skeletal muscle)

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27
Q

What is the normal size of the palpebral fissure?

A

27-30mm long, 8-11mm high

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28
Q

What is the excursion of the upper lid generated by the levator alone?

A

15mm (extra 2mm if using the frontalis in addition)

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29
Q

What are the segments of the eyelid (from dermal surface inward)?

A

skin, eyelid margin, subq tissue, orbicularis muscle, orbital septum, levator muscle, muller muscle, tarsus, conjunctiva

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30
Q

Where is the superior eyelid fold located?

A

at the upper border of the tarsus, at the initial insertion of the levator aponeurosis

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31
Q

What does the gray line of the eyelid margin indicate?

A

1) the most superficial portion of the orbicularis muscle, 2) the muscle of Riolan, and 3) the avascular plane of the lid

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32
Q

How many rows of eyelashes are there?

A

2 to 3

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33
Q

What are glands of Zeis?

A

modified sebaceous glands associated with the cilia

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34
Q

What are glands of Moll?

A

apocrine sweat glands of skin

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35
Q

Which CN innervates the orbicularis?

A

VII

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36
Q

Are meibomian orifices and lacrimal punctum anterior or posteiror to the gray line?

A

posterior

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37
Q

What are the two parts of the orbicularis?

A

Orbital and palpebral

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38
Q

Does the orbital part of the orbiclularis have involuntary functions?

A

No, only the palpebral part of the orbicularis does

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39
Q

What is the orbital septum?

A

a thin sheet of connective tissue that encircles the orbit as an extension of the periosteum of the roof and floor of the orbit

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40
Q

To which surface of the levator muscle does the orbital septum attach?

A

Anterior surface

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41
Q

How long is the levator muscle and its tendon?

A

muscle 40mm, muscle + tendon 50-55mm long

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42
Q

Which CN innervates the levator?

A

CN III

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43
Q

What is the Muller muscle?

A

A smooth, smypathetically innervated muscle originating from the undersurface of the levator muscle in the upper eyelid

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44
Q

How are the tarsal plates connected to the orbital margins?

A

by the medial and lateral palpebral ligaments

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45
Q

How much taller is the upper tarsus than the lower tarsus?

A

3x taller (11mm vs. 4 mm)

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46
Q

How many meibomian orifices are there at the eylid margin?

A

30 on upper lid, 20 on lower lid

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47
Q

What is distichiasis?

A

aberrant growth of cilia through the orificies of the meibomian glands

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48
Q

Is the palpebral conjunctival epithelium keratinized?

A

No

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49
Q

From which systems does the blood supply of the eyelids arise?

A

Facial (ECA) and Orbital (ICA)

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50
Q

Where does the marginal arterial arcade of the eyelid run?

A

between orbicularis and tarsus or within tarsus

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51
Q

What are the venous systems draining the eyelids?

A

Superficial/pretarsal system (IJ/EJ) and Deep/Posttarsal (cavernous sinus)

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52
Q

Are lymphatic vessels present in the eyelids?

A

Yes, but not in the orbit

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53
Q

Where do the lymphatics of the eyelids drain?

A

medial group drains to submandibular LNs, lateral group drains to preauricular LNs

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54
Q

Is the plica semilunaris a vestigial structure?

A

yes, it is analogous to the nictitating membrane of other animals

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55
Q

Are the lacrimal glands endocrine or exocrine?

A

Exocrine

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56
Q

What are the 2 cell types contained in the lacrimal gland?

A

1) Acinar cells lining the lumen, 2) Myoepithelial cells

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57
Q

What types of nerve fibers does the lacrimal gland receive?

A

cholinergic, VIP-ergic, sympathetic, and sensory from V1

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58
Q

What are three divisions of the conjunctiva?

A

Papebral, Forniceal, and Bulbar

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59
Q

Does the bulbar conjunctiva fuse with the Tenon capsule?

A

Yes

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60
Q

What is the Tenon capsule?

A

The Tenon capsule (fascia bulbi) is an envelope of elastic connective tissue that fuses posteriorly with the optic nerve sheath and anteriorly with the intermuscular septum, 3mm posterior to the limbus. The Tenon capsule is the cavity in which the globe moves.

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61
Q

From where do the anterior and posterior ciliary arteries arise?

A

the ophthalmic artery

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62
Q

What do the posterior ciliary arteries supply?

A

Whole uveal tract, cilioretinal artery, sclera, margin of cornea, adjacent conjunctiva

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63
Q

What do the anterior ciliary arteries supply?

A

SR, MR, IR muscles

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64
Q

What are the vortex veins?

A

Veins draining the choroid. There are usually 4-7 of vortex veins, at least 1 in each quadrant, exiting the eye just posterior to the equator.

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65
Q

What is the shape of the globe?

A

an oblate spheroid

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66
Q

What is the average transverse diameter of the adult eye?

A

24mm

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67
Q

What is the average volume of the adult globe?

A

6.5 to 7 cc

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68
Q

What are three things contained in tears aside from oil, water, and mucus?

A

immunoglobulins, lysozyme, and lactoferrin

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69
Q

What is the power of the anterior surface of the cornea?

A

49D

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70
Q

What structure attaches the basal epithelium of the cornea to the epithelial basement membrane?

A

hemidesmosomes

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71
Q

What non-epithelial cells are found in the corneal epithelium?

A

Histiocytes, macrophages, lymphocytes, pigmented melanocytes, and Langerhans cells

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72
Q

Is Bowman layer replaced after injury?

A

No

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73
Q

How thick is Bowman layer?

A

8-14 microns thick

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74
Q

What types of collagen are found in the corneal stroma?

A

Types I, III, V, and VI

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75
Q

What percent of the corneal volume is made up by keratocytes?

A

5%

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76
Q

Where is the density of keratocytes highest in the corneal stroma?

A

Anteriorly

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77
Q

What is the Descemet membrane?

A

The basement membrane of the corneal endothelium.

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78
Q

What are peripheral excrescences in the Descemet membrane called?

A

Hassal-Henle warts (common in the elderly), as opposed to Guttae (which are central)

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79
Q

Which way does the apical surface of a corneal endothelial cell face?

A

Toward the anterior chamber

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80
Q

Are desmosomes seen between corneal endothelial cells?

A

No, but junctional complexes are present between contiguous cells

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81
Q

Where is the sclera the thinnest?

A

at the insertions of the rectus muscles (0.3mm)

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82
Q

Where is the sclera the thickest?

A

around the optic nerve head (1mm)

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83
Q

What are included in the corneal limbus?

A

Conjunctiva and limbal palisades, Tenon capsule, episclera, corneoscleral stroma, aqueous outflow apparatus

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84
Q

What are the two parts of the surgical limbus?

A

1) anterior bluish gray zone from Bowman termination to Descemet termination, 2) Posterior white zone from Descemet termination (Schwalbe line) to scleral spur

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85
Q

What are conditions that cause an increase in the depth of the anterior chamber?

A

aphakia, pseudophakia, and myopia

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86
Q

What is the normal volume of the anterior chamber?

A

200 microliters

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87
Q

What are the two primary means of aqueous drainage?

A

Schlemm canal and uveoscleral pathway

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88
Q

What is the trabecular meshwork?

A

a circular spongework of connective tissue lined by trabeculocytes

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89
Q

What are the 3 layers of the TM?

A

1) Uveal portion, 2) Corneoscleral meshwork, 3) Juxtacanalicular tissue

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90
Q

Which portion of the TM provides the most resistance to outflow?

A

Juxtacanalicular connective tissue

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91
Q

What are the 3 points of connection of the uvea to the sclera?

A

1) Scleral spur, 2) Vortex veins, 3) optic nerve

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92
Q

How is aqueous drained via Schlemm canal?

A

25-30 collector channels arise from the canal and drain into the deep and intrascleral venous plexuses, which in turn drain to the episcleral venous plexus. 8 of the collector channels drain directly to the episcleral venous plexus as “aqueous veins.”

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93
Q

What does eye color correspond to?

A

The amount of pigment in the anterior border layer and deep stroma of the iris.

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94
Q

What is the orientation of the fibers of the pupillary sphincter muscle?

A

circular (adjacent to pupillary border)

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95
Q

What is the orientation of the fibers of the iris dilator muscle?

A

radial (peripheral)

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96
Q

What type of innervation does the iris dilator muscle have?

A

Both sympathetic and parasympathetic! Cholinergic parasympathetic innervation may inhibit the contraction of the dilator muscle

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97
Q

What is the primary innervation of the iris sphincter muscle?

A

Parasympathetic innervation from nucleus of CN III. It appears to also have secondary sympathetic innervation that inhibits contraction (and thereby inhibits pupillary constriction).

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98
Q

What are the two primary functions of the ciliary body?

A

aqueous humor formation and lens accommodation

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99
Q

How far from the corneal limbus is the pars plana of the ciliary body?

A

3-4mm posterior

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100
Q

Which is more vascular, the pars plana or the pars plicata of the ciliary body?

A

the pars plicata is richly vascularized

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101
Q

What is the lining of the ciliary body?

A

2 layers of epithelial cells (non-pigmented and pigmented epithelial layers)

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102
Q

What is the main arterial supply of the ciliary body?

A

the anterior ciliary arteries and long posterior ciliary arteries

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103
Q

What are the three layers of fibers in the ciliary muscle?

A

1) longitudinal, 2) radial, 3) circular

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104
Q

What is the primary innervation of the ciliary body?

A

Parasympathetic fibers from CN III via the short ciliary nerves

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105
Q

What do cholinergic drugs do to the ciliary body muscle?

A

They cause it to contract, which opens up the TM via its attachments to the sceral spur, thereby increasing aqueous outflow

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106
Q

Where does the perfusion of the choroid come from?

A

The short posterior ciliary arteries and the perforating anterior ciliary arteries

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107
Q

In to what does blood from the choroid drain?

A

The vortex veins

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108
Q

What is Bruch membrane?

A

A PAS-positive layer resuting from the fusion of the basal laminae of the RPE and choriocapillaris

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109
Q

What are the layers of the Bruch membrane?

A

1) basal lamina of RPE, 2) inner collagenous zone, 3) porous band of elastic fibers, 4) outer collagenous zone, 5) basal lamina of the choriocapillaris

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110
Q

Is Bruch membrane permeable to fluorescein?

A

Yes

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111
Q

Are the medium and large choroidal vessels permeable to fluorescein?

A

No, but the choriocapillaris is

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112
Q

On what does the degree of fundus pigmentation viewed ophthalmoscopically depend?

A

The number of pigmented melanocytes in the choroid

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113
Q

Does the degree of pigmentation of the choroid affect photocoagulation?

A

Yes

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114
Q

What is the diameter of the lens in the adult?

A

9-10mm

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115
Q

What is the depth of the lens in the adult?

A

5-6mm

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116
Q

What is the lens capsule?

A

A basal lamina put down by the lens epithelial cells, rich in type IV collagen

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117
Q

Does the thickness of the anterior capsule change during life?

A

Yes, it continues to grow, while the posterior capsule does not

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118
Q

Is lens epithelium present underneath the posterior capsule?

A

No

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119
Q

What is the germinative zone of the lens?

A

A set of peripheral meridional rows of cuboidal pre-equatorial lens epithelial cells that undergo mitotic division

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120
Q

Of what material are lens zonules made?

A

fibrillin

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121
Q

What is the average diameter of the macula?

A

5-6mm

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122
Q

What is the composition of the RPE?

A

A monolayer of hexagonal cells

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123
Q

What are the functions of the RPE?

A

1) Vitamin A metabolism, 2) maintenance of outer blood-retina barrier, 3) phagocytosis of outer segments, 4) absorption of light, 5) heat exchange, 6) formation of basal lamina, 7) production of MPS matrix, 8) active transport into and out of RPE

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124
Q

What is a retinal detachment?

A

separation of the neurosensory retina from the RPE

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125
Q

From what do lipofuscin granules arise?

A

the discs of photorecptor outer segments. They represent residual bodies arising from phagosomal activity

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126
Q

What are phagosomes?

A

membrane-enclosed packets of disc outer segments that have been engulfed by the RPE

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127
Q

What surrounds the photoreceptor outer segments?

A

An MPS matrix, secreted by the RPE

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128
Q

What types of cells are found in the inner nuclear layer?

A

Bipolar, Amacrine, and Horizontal cells; (also, Muller-type glial cells)

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129
Q

What types of cells are found in the outer nuclear layer?

A

Photoreceptor cell bodies

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130
Q

How many rods and cones are there?

A

120M rods, 6M cones

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131
Q

What is the blood supply of the inner retina?

A

Branches of the cnetral retinal artery and, in 30% of people, a cilioretinal artery branching from the ciliary circulation

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132
Q

Are retinal arteries permeable to fluorescein?

A

No, they have tight junctions and maintain the blood-retina barrier

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133
Q

Is the external limiting membrane fenestrated?

A

Yes

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134
Q

What is the OPL called in the fovea?

A

the Henle fiber layer

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135
Q

Is the OPL thicker in the macula?

A

Yes

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136
Q

Of what does the OPL consist?

A

Photoreceptor axons

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137
Q

Of what does the IPL consist?

A

axons of bipolar and amacrine cells, as well as the dendrites of ganglion cells

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138
Q

Of what does the NFL consist?

A

axons of the ganglion cells

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139
Q

Are axons of ganglion cells myelinated?

A

Not within the eye. They are myelinated only after they pass through the lamina cribrosa

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140
Q

What is the histologic definition of the macula?

A

The region with more than 1 layer of ganglion cell nuclei (plus the foveola)

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141
Q

What are the two major pigments of the macula?

A

zeaxanthin (cone-dense areas) and lutein (rod-dense areas)

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142
Q

What is the diameter of the fovea?

A

1.5mm

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143
Q

What is the diameter of the foveola?

A

0.35mm

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144
Q

Which layers are absent in the foveola?

A

NFL, GCL, IPL, INL

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145
Q

Is the FAZ different from the foveola?

A

It is roughly the same size and location, but characterized only by its avascularity

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146
Q

What type of photoreceptors are present in the foveola?

A

ONLY cones

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147
Q

How far from Schwalbe line is the the ora serrata?

A

5.75mm to 6.5mm

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148
Q

Of what does the vitreous consist?

A

99% water, plus MPS and hyaluronic acid

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149
Q

What is the path of the fibers forming CN I?

A

from olfactory receptors in mucous membrane of the nose to the olfactory bulb (where they form the nerve)

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150
Q

What are the 4 topographic areas of the optic nerve?

A

1) Intraocular region, 2) Intraorbital region, 3) Intracanalicular region, 4) Intracranial region

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151
Q

What is the averatge length of the optic nerve?

A

40mm (35-55mm)

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152
Q

What is the length of the intraorbital portion of the optic nerve?

A

25-30mm, via a sinuous course

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153
Q

What is the average size of the optic disc?

A

1.5mm (horizontal) x 1.75mm vertical

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154
Q

What are the 4 parts of the optic nerve?

A

1) superficial nerve fiber layer, 2) prelaminar area, 3) laminar area, 4) retrolaminar area

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155
Q

Where within the optic nerve head are fibers from the macula?

A

Lateral

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156
Q

How do ganglion cell axons pass through the lamina cribrosa?

A

in fascicles formed by astrocytic glial cells

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157
Q

What leads to enlargement of the optic cup?

A

Loss of ganglion cell axons and supporting glial elements

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158
Q

How many tissue plates are in the lamina cribrosa?

A

10

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159
Q

What percent of the optic nerve head volume is made up by astrocytes?

A

10%

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160
Q

What types of collagen are found in the lamina cribrosa?

A

Type I and Type III, in addition to elastin, laminin, and fibronectin

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161
Q

What are the functions of the lamina cribrosa?

A

1) scaffold for optic nerve axons,2) point of fixation for CRA and CRV, 3) reinformcement of posterior segment of globe

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162
Q

What is the diameter of the optic nerve posterior to the lamina cribrosa?

A

3mm (increases due to myelination of nerve fibers)

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163
Q

What happens to the dural sheath of the optic nerve at the optic canal?

A

It fuses to the periosteum, completely immobilizing the nerve

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164
Q

What divides the nerve into fascicles?

A

The pia mater

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165
Q

What is the blood supply of the optic nerve in the optic canal?

A

Pial vessels from the ophthalmic artery

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166
Q

What is the blood supply of the retrolaminar nerve?

A

Pial vessels and short posterior ciliary vessels, CRA, and recurrent choroidal arteries

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167
Q

What is the blood supply of the lamina cribrosa?

A

The short posterior ciliary arteries and branches of the arterial circle of Zinn-Haller

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168
Q

What is the blood supply of the prelaminar nerve?

A

short posterior ciliary arteries (and cilioretinal artery if present) and possibly recurrent choroidal arteries

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169
Q

What is the blood supply of the NFL?

A

the CRA

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170
Q

What is the blood supply of the intracanalicular nerve?

A

ophthalmic artery

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171
Q

What is the blood supply of the intracranial optic nerve?

A

ICA and ophthalmic artery

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172
Q

What percent of the volume of the optic nerve consists of macular nerve fibers?

A

80%

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173
Q

Which layers of the LGN receive fibers from the contralateral optic nerve?

A

1, 4, and 6

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174
Q

What gives rise to the upper homonymous “pie in the sky” defect?

A

Damage to the optic radiation in the anterior temporal lobe

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175
Q

What is the blood supply of the visual cortex?

A

The posterior cerebral artery

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176
Q

What does CN III supply?

A

SR, MR, IR, IO, levator palpebrae, pupillary sphincter, and ciliary muscle

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177
Q

Which nucleus of CN III provides innervation to the ciliary muscle and pupillary sphincter?

A

The Edinger-Westphal nucleus

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178
Q

Where does CN III divide into superior and inferior divisions?

A

Usually after passing through the annulus of Zinn in the orbit (sometimes within the cavernous sinus)

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179
Q

What is a sensitive early sign of compression of CN III?

A

loss of pupillary constriction ability

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180
Q

What is the path of the pupillary light reflex?

A

light activates photoreceptors –> retinal ganglion cells –> axons cross in the optic chiasm –> in optic tract, pupillary fibers leave visual fibers and go to pretectal nuclei at superior colliculus –> efferents to EW nuclei with partial decussation –> parasympathetic fibers leave from each EW nucleus and join CN III –> fibers join inferior division of CN III –> synapse in ciliary ganglion –> give rise to short ciliary nerves (3%-5% are pupillomotor)

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181
Q

What is the path of the pupillary near reflex?

A

reflex initiated in occipital association cortex –> relay inpretectal and tegmental areas –> pass to EW nuclei, motor nuclei of MR muscles, and nuclei of CN VI –> efferents to MR, LR, pupillary sphincter, and ciliary muscle

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182
Q

What actions are involved in the near reflex?

A

1) Accommodation, 2) Pupil constriction, 3) converence

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183
Q

Which CN has the longest intracranial course?

A

CN IV (75mm)

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184
Q

Which CN is the only CN to be completely decussated?

A

CN IV

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185
Q

Which CN is the only CN to exit dorsally from the brainstem?

A

CN IV

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186
Q

Does CN IV enter the orbit through the annulus of Zinn?

A

No, it enters the orbit through the superior orbital fissure outside the annulus of Zinn

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187
Q

What are the 4 nuclei of the CN V nuclear complex?

A

1) mesencephalic nucleus, 2) main sensory nucleus, 3) spinal nucleus and tract, 4) motor nucleus (in the pons)

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188
Q

What does the main sensory nucleus of CN V receive?

A

light touch from the skin and mucous membranes

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189
Q

What does the spinal nucleus of CN V receive?

A

pain and temperature, as well as cutaneous components of CN VII, IX, and X

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190
Q

What does the mesencephalic nucleus of CN V receive?

A

prioprioception and deep sensation from masticatory, facial, and extraocular muscles

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191
Q

Which muscles does the motor nucleus of CN V innervate?

A

muscles of mastication (pterygoid, masseter, temporalis), tensor tympani, tensor veli palatini, mylohyoid, anterior belly of digastric

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192
Q

Where is the trigeminal ganglion located?

A

in Meckel cave, a recess near the apex of the petrous part of the temporal bone in the middle cranial fossa. It is posterolateral to the cavernous sinus.

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193
Q

What are the 3 branches of V1?

A

frontal, lacrimal, and nasociliary

194
Q

What are the two divisons of the frontal branch of V1?

A

supraorbital nerve and supratrochlear nerve

195
Q

What does the lacrimal branch of V1 innervate?

A

lacrimal gland and neighboring conj and skin

196
Q

What does the nasociliary branch of V1 innervate?

A

Via nasal branches (anterior ethmoidal nerve): middle and inferior turbinates, septum, lateral nasal wall, tip of nose. Via infratrochlear branch: lacrimal drainage system, conj, skin of medial canthus. Via long ciliary nerves: ciliary body, iris, cornea, sympathetic innervation to iris dilator muscle; Via short ciliary nerves: globe sensation, parasympathetic fibers to pupillary sphincter and ciliary muscle

197
Q

What are the 5 motor branches of CN VII?

A

Temporal, zygomatic, buccal, mandibular, cervical

198
Q

What is the cavernous sinus?

A

an interconnected series of venous channels located just posterior to the orbital apex and ateral to the sphenoidal (air) sinus and pituitary fossa

199
Q

What are the structures located within the cavernous sinus?

A

1) the ICA, 2) sympathetic carotid plexus, 3) CN III, 4) CN IV, 5) ophthalmic and maxillary branches of CN V, 6) CN VI

200
Q

What are the primary tissues invovled in the process of ocular development?

A

Head epidermis, neuroectoderm, and mesenchyme

201
Q

What are three important factors in the development of the eye?

A

1) growth factors, 2) homeobox genes, 3) neural crest cells

202
Q

Which growth factors are most important in ocular development?

A

FGF, TGF-beta 1 and 2, IGF-1

203
Q

Which homeobox gene is expressed in the area of surface ectoderm destined to form the corneal epithelium?

A

HOX 8.1

204
Q

From where do NCCs arise?

A

From neuroectderm located at the crest of the neural folds at approximately the same time that the folds fuse to form the neural tube.

205
Q

From which germ layer do the endothelial cells lining blood vessels of the ey arise?

A

mesoderm

206
Q

Which eye/orbit tissues derive from surface ectoderm?

A

Epithelium, glands, and cilia of skin of eyelids and caruncle; conjunctival epithelium, lens, lacrimal gland, lacrimal drainage system, vitreous

207
Q

Which eye/orbit tissues derive from neuroectoderm?

A

retina, RPE, pigmented and non-pigmented ciliary epithelium, pigmented iris epithelium, sphincter and ilator muscles of irirs, optic nerve, axons, and glia, vitreous

208
Q

Which eye/orbit tissues derive from cranial NCCs?

A

corneal stroma and endothelium, sclera, TM, sheaths and tendons of EOMs, connective tissues of iris, ciliary muscle, choroidal stroma, melanocytes, meningeal sheaths of optic nerve, Schwann cells of ciliary nerves, ciliary ganlgion, cartilage, connective tissue of orbit, muscular layer and connective tissue sheaths of vessels, all midline and inferior orbital bones, parts of orbital roof and lateral rim

209
Q

Which eye/orbit tissues derive from mesoderm?

A

fibers of EOMs, endothelium of blood vessels, temporal portion of sclera, vitreous

210
Q

What are the neurocristopathies?

A

congenital and developmental anomalies involving NCC-derived tissues, usually deriving from improper migration or differentiation of NCCs

211
Q

When does the neural tube close?

A

at the end of the third week of development

212
Q

What 3 events important to the development of the eye occur as the neural tube closes?

A

1) optic pits develop from the optic sulci, 2) NCCs begin to migrate, 3) the anterior neural tube flexes ventrally

213
Q

What are the optic sulci?

A

small depressions present in the cephalic neuroectocderm

214
Q

From what do the optic vesicles arise?

A

The optic pits, as the optic pits deepen

215
Q

From what does the optic cup arise?

A

The optic vesicle, as its temporal and lower walls are invaginated

216
Q

What does the outer layer of the optic cup become?

A

the RPE

217
Q

What does the inner layer of the optic cup become?

A

the retina

218
Q

What is the embryonic fissure?

A

The indentation between the folds or margins of the optic cup

219
Q

At what stage of development does the lens placode form?

A

28 days

220
Q

At what stage of development do eyelid folds appear?

A

2nd month

221
Q

At what stage of development do axons from ganglion cells migrate to optic nerve?

A

2nd month

222
Q

At what stage of development does Bruch membrane appear?

A

2nd month

223
Q

At what stage of development do rod and cone precursors differentiate?

A

3rd month

224
Q

At what stage of development do the vortex veins pierce the sclera?

A

3rd month

225
Q

At what stage of development do the eyelid folds meet and fuse?

A

3rd month

226
Q

At what stage of development does Descemet membrane form?

A

4th month

227
Q

At what stage of development does Schlemm canal appear?

A

4th month

228
Q

At what stage of development does the hyalid system start to regress?

A

4th month

229
Q

At what stage of development do the eyelids begin to separate?

A

5th month

230
Q

At what stage of development do the photoreceptors develop inner segments?

A

5th month

231
Q

At what stage of development does the dilator muscle of the iris form?

A

6th month

232
Q

At what stage of development do the photoreceptors develop outer segments?

A

7th month

233
Q

At what stage of development do the choroidal melanocytes produce pigment?

A

7th month

234
Q

At what stage of development does the lamina cribrosa form?

A

7th month

235
Q

At what stage of development does chamber angle formation complete?

A

8th month

236
Q

At what stage of development do retinal vessels reach the periphery?

A

9th month

237
Q

At what stage of development do fibers of the optic nerve complete myelination to the point of the lamina cribrosa anteriorly?

A

9th month

238
Q

At what stage of development does the pupillary membrane disappear?

A

9th month

239
Q

At what stage of development does the retina begin to differentiate?

A

within 1 month

240
Q

At what stage of development does the hyaloid artery enter the vitreous?

A

5th week

241
Q

From which embryonic structure does the optic nerve arise?

A

the optic stalk

242
Q

What are the primary functions of the tear film?

A

1) To provide a smooth optical surface; 2) to serve as a medium for removal of debris; 3) to protect the ocular surface; 4) to supply oxygen, growth factors and other compounds to the epithelium

243
Q

What are the three parts of the tear film?

A

1) Tear meniscus, 2) Precorneal tear film, 3) conjunctival tear film

244
Q

What is the thickness of the precorneal tear film?

A

3.4 microns

245
Q

What are the three layers of the tear film?

A

anterior lipid layer, middle aqueous layer, posterior mucin layer

246
Q

What portion of the tear film is water?

A

98.20%

247
Q

What is the normal rate of tear secretion in the anesthetized and unanesthetized states?

A

unanesthetized: 3.8 microL/min, anesthetized: 1.8 microL/min by Schirmer method

248
Q

What are the functions of the lipid layer of the tear film?

A

1) slow evaporation, 2) contribute to optical properties of tear film, 3) maintain hydrophobic barrier to increase surface tension, 4) prevent damage to lid margin skin by tears

249
Q

What are the electrolytes found in the tear film?

A

Na+, K+, Ca2+, Mg,2+ Cl-, HCo3-

250
Q

What is the predominant innervation of the lacrimal gland?

A

parasympathetic

251
Q

Which immunoglobulins are found in the tear film?

A

IgA, secretory IgA (occasionally IgG in ocular inflammation, IgE in vernal conjunctivitis)

252
Q

What are the antimicrobial components of the tear film?

A

lysozyme, lactoferrin, phospholipase A2, lipocalins, defensins, interferon

253
Q

What are the solutes found in the tear film?

A

urea, glucose, lactate, citrate, ascorbate, amino acids

254
Q

What is the function of the aqueous layer of the tear film?

A

1) supply oxygen to the corneal epithelium, 2) maintain constant electrolyte composition, 3) provide antimicrobial defense, 4) smooth minute irregularities of corneal surface, 5) wash away debris, 6) modulate corneal and conjunctival epithelial cell function

255
Q

What are the functions of the mucin layer of the tear film?

A

1) convert the corneal epithelium from a hydrophobic to a hydrophilic layer, 2) interact with tear lipid layer to lower surface tension, 3) trap exfoliated surface cells, foreign particles, and bacteria, 4) lubricate the eyelids as they pass over the globe

256
Q

What are 2 means of stimulating tear secretion?

A

1) Nerve stimulation and 2) hormone secretion (alphaMSH, ACTH, VIP)

257
Q

What are 4 reasons for tear film dysfunction?

A

1) change in amount of tear film constituents, 2) change in composition of tear film, 3) uneven dispersion of tear film due to corneal surface irregularity, 4) ineffective distribution of tear film by lids

258
Q

What is the innervation of the cornea?

A

The long posterior ciliary nerves (branches of V1) penetrate the cornea in 3 planes: scleral, episceral, and conjunctival.

259
Q

Are corneal nerves myelinated?

A

No, the corneal nerves lose their myelin sheath 1-2mm from the limbus

260
Q

Where is the sub-basal plexus located?

A

Just posterior to Bowman layer (underneath the basal epithelium and Bowman layer). It sends branches anteriorly into the epithelium

261
Q

From where is oxygen for the cornea derived?

A

pre-corneal tear film, lid vasculature, aqueous humor

262
Q

What is the primary metabolic substrate for the cornea?

A

glucose

263
Q

How is glucose metabolized by the cornea?

A

Via all 3 pathways (TCA cycle, anaerobic glycolysis, HMP shunt). TCA cycle more active in endothelium than epithelium.

264
Q

What is the ideal ionic dissociation characteristic of an organic molecule for penetrating the cornea?

A

The organic molecule should be able to dissociate into ions at physiologic pH and temperature (i.e., after penetrating the corneal epithelium and entering the stroma)

265
Q

What happens to Bowman layer in PRK, LASEK, and LASIK?

A

Bowman layer is lost during PRK and LASEK for myopia correction; Bowman layer is transected but retained in LASIK

266
Q

How are adjacent lamellae of corneal stroma positioned relative to one another?

A

approximately orthogonal to one another

267
Q

What are the GAGs found in the corneal stroma?

A

1) keratan sulfate, 2) chondroitin sulfate, 3) dermatan sulfate

268
Q

Which MMP is found in normal healthy cornea?

A

MMP-2

269
Q

Which MMPs are found after corneal injury?

A

MMP-1, MMP-3, and MMP-9

270
Q

What is the predominant type of collagen in Descemet membrane?

A

Type IV collagen

271
Q

From which germ layer is the smooth muscle of the iris and ciliary body derived?

A

Neuroectoderm (unlike smooth muscle elsewhere in the body, which is derived from mesoderm)

272
Q

What types of receptors are expressed by the iris-ciliary body complex?

A

adrenergic, muscarinic cholinergic, peptidergic, prostaglandin, serotonin, platelet activating factor, growth factor receptors

273
Q

Compared to plasma, how much protein is there in aqueous humor?

A

aqueous has 1/500th of the amount of protein found in plasma

274
Q

What are the two means by which aqueous is produced?

A

1) passive (diffusion and ultrafiltration), 2) active (energy-dependent secretion, including carbonic anhydrase II activity)

275
Q

What is ultrafiltration (with regard to aqueous production)?

A

the nonenzymatic component of aqueous formation, dependent upon IOP, blood pressure, and blood osmotic pressure in the ciliary body

276
Q

What is the mechanism of action of PG analogues on IOP?

A

enhancement of aqueous outflow

277
Q

What do PGs of type E and F do when used topically at high concentrations?

A

They cause miosis, elevation of IOP, increase in aqueous protein content, and entry of WBCs into aqueous and tear fluid.

278
Q

What are the primary receptors found on the ciliary muscle and iris sphincter?

A

muscarinic cholinergic receptors

279
Q

What are the primary receptors found on the iris dilator muscle?

A

alpha-adrenergic receptors

280
Q

Which neurotransmitters are used by the sensory nerves of the iris muscles?

A

substance P and CGRP

281
Q

By what mechanisms do miotic agents act?

A

1) stimulate the iris sphincter muscle (cholinergic agonist) or 2) block the iris dilator muscle (alpha-adrenergic blockade)

282
Q

What are the mechanisms by which cholinergic agonist miotics act?

A

1) Direct agonism through ACh, carbachol, or pilocarpine or 2) Accumulation of ACh via AChE blocker (reversible or irreversible)

283
Q

Which AChE blockers are reversible?

A

physostigmine and neostigmine

284
Q

Which AChE blockers are irreversible?

A

diisopropyl fluorophosphate (DFP) and echothiophate iodide

285
Q

What are the two mechanisms for the of dilator blocking miotics?

A

1) inhibition of NE release by depletion of NE stores (guanethidine), 2) blockage of alpha1-adrenergic receptors of dilator muscle (thymoxamine, dapiprazole, phenoxybenzamine, dibenamine, phentolamine)

286
Q

What are the two mechanisms of mydriatic agents?

A

1) stimulating the dilator muscle (alpha adrenergic agonists) or 2) blocking the iris sphincter muscle (cholinergic blockade)

287
Q

What are the three mechanisms of adrenergic agonist mydriatics?

A

1) increasing NE release (hydroxyamphetamine), 2) blocking NE reuptake (cocaine), 3) directly stimulating alpha1 receptors of dilator muscle (phenylephrine)

288
Q

Why is an anticholinergic agent both mydriatic and cycloplegic, while an adrenergic agent is only mydriatic?

A

The ciliary body has cholinergic innervation, and thus, paralysis of the ciliary body (i.e. cycloplegia) requires an anticholinergic.

289
Q

What are common cycloplegic agents?

A

atropine, cyclopentolate, and tropicamide (in order of decreasing duration of action)

290
Q

Which types of drugs decrease aqueous humor production?

A

beta-antagonists and alpha2 agonists

291
Q

Which types of drugs increase trabecular outflow?

A

miotics (alpha1 agonists and anticholinergic) and adrenergic agonists

292
Q

Which types of drugs increase uveoscleral outflow?

A

1) prostaglandins and 2) alpha agonists

293
Q

What is the rate of secretion of aqueous humor by the ciliary epithelium?

A

2-3 microL/min

294
Q

What are the two types of ciliary epithelium and in which direction does each face?

A

1) Non-pigmented epithelium –> aqueous humor, 2) pigmented epithelium –> stroma

295
Q

What are the 3 steps in the formation of aqueous?

A

1) uptake of solute and water by surface PE cells, 2) transfer from PE to NPE cells through gap junctions, 3) transfer of solute and water by NPE cells into the posterior chamber

296
Q

What is contained in the aqueous humor other than water?

A

1) inorganic ions and organic anions, 2) carbohydrates, 3) glutathione and urea, 4) proteins, 5) growth-modulatory factors, 6) oxygen and CO2

297
Q

What is the ratio of plasma calcium to aqueous calcium?

A

2 to 1

298
Q

What are the commonly found organic anions in aqueous?

A

1) Lactate most abundant, 2) ascorbate (vit C) 10x greater than plasma

299
Q

What is the glucose concentration in aqueous relative to plasma?

A

70% of plasma glucose concentration

300
Q

What are the growth-modulatory factors found in aqueous?

A

1) TGF-beta1 and beta2, 2) aFGF, bFGF, 3) IGF-I, 4) IGFBPs, 5) VEGF, 6) transferrin

301
Q

What are the 3 VEGF receptors?

A

1) VEGFR1 – both positive and negative angiogenic effects, 2) VEGFR2 – primary mediator of mitogenic, angiogenic, and vascular permeability effects of VEGF-A, 3) VEGFR3 – mediates angiogenic effects on lymphatic vessels

302
Q

Which is the only member of the VEGF family that is induced by hypoxia?

A

VEGF-A. It is a critical regulator of angiogenesis and a potent inducer of vascular permeability.

303
Q

What is the partial pressure of oxygen in the aqueous?

A

55mmHg

304
Q

What is the partial pressure of CO2 in aqueous?

A

40-60mmHg

305
Q

What contributes to the high refractive index of the lens?

A

soluble proteins called crystallins

306
Q

What type of collagen makes up the lens capsule?

A

Type IV collagen

307
Q

Where do the zonular fibers insert on the lens capsule?

A

anteriorly and posteriorly near the lens equator

308
Q

How many cells deep is the anterior lens epithelium?

A

1 cell deep anteriorly; germinative zone is near equator

309
Q

What are the two proteins expressed in large amounts by elongating lens fibers?

A

Crystallins and Major intrinsic protein (MIP, an aquaporin)

310
Q

Do terminally differentiated lens fibers have nuclei, mitochondria, or other organelles?

A

No, they disintegrate

311
Q

What are the two portions of the lens fiber mass?

A

The cortex (laid down after age 20) and the nucleus (laid down from embryogenesis to age 20)

312
Q

What compound is lost in the lens with age, particularly in the nucleus?

A

phospholipid

313
Q

What are lens crystallins?

A

A diverse group of proteins expressed in high abundance in the lens fiber cells and throught to provide transparency and refractile properties to the lens. They make up 90% of the total lens protein.

314
Q

What are the two groups of crystallin proteins?

A

alpha-crystallin family and beta,gamma cyrstallin family

315
Q

Is alpha-crystallin a member of the heat-shock protein family?

A

Yes, it is inducible by heat and other stresses.

316
Q

What is the chaperone-like activity of alpha crystallins?

A

they bind proteins that are beginning to denature and prevent further denaturation and aggregation

317
Q

Where are the gamma crystallins found?

A

In the nuclus, as they are mostly expressed in early development

318
Q

Where are the longest-lived proteins in the body found?

A

in the lens (at the center of the nucleus) – synthesized before birth

319
Q

Is the oxygen tension in the lens higher or lower than that of other tissues?

A

Lower, it is avascular and relies on the diffusion from the aqueous

320
Q

What is a critical factor in the cascade leading to hyperglycemic cataracts in animal models?

A

aldose reductase

321
Q

What is the function of the vitreous?

A

act as a conduit for nutrients and other solutes to and from the lens, occupy the major volume of the globe

322
Q

What is the physical structure of the vitreous?

A

a gel composed of a collagen framework interspersed with hydrated hyaluronan molecules

323
Q

What determines whether the vitreous is liquid or gel?

A

the amount of collagen (more collagen –> more gel-like)

324
Q

What is the function of the collagen in the vitreous?

A

The collagen fibrils supply resistance to tensile forces and give plasticity to the vitreous

325
Q

What is the function of the hyaluronan in the vitreous?

A

it resists compression and confers viscoelastic properties

326
Q

What is the composition of the vitreous?

A

98% water, 0.15% macromolecules (collagen, hyaluronan, soluble proteins, the rest is ions/solutes

327
Q

What are two important enzymes found in vitreous?

A

hyaluronidase and MMP-2

328
Q

What are the 3 types of collagen comprising collagen fibrils in the vitreous?

A

1) Type II (major component), 2) Type IX (on surface of fibrils), 3) Type V/XI (projects from surface of fibril)

329
Q

What are two glycoproteins thought to be important in the structure of the collagen fibril?

A

opticin and VIT1

330
Q

What percent of the vitreous is typically liquid by age 80?

A

50%

331
Q

What occurs to collagen fibrils in the process of vitreous liquefaction?

A

breakdown of thin collagen fibrils into smaller fragments, thought to be due to loss of Type IX collagen shielding of the fibrils with age

332
Q

What are 2 major physical changes in ocular characteristics after vitrectomy?

A

1) 300x to 2000x reduction in viscosity and 2) marked increase in oxygen tension at the retina (due to rapid diffusion from anterior to posterior segment)

333
Q

What happens to vitreous in an area of hemorrhage?

A

The vitreous becomes liquified in response to phagocytic inflammatory reaction (if not already liquefied)

334
Q

What are the types of neural retinal cells?

A

1) photoreceptors (rods and 3 cone types), 2) bipolar cells (rod on- and cone on- and off- bipolars), 3) interneurons (horizontal and amacrine cells), 4) ganglion cells, 5) supporting cells (astroglia, oligodendroglia, Schwann cells, microglia, vascular endothelium, pericytes)

335
Q

What part of the photoreceptor is involved directly in phototransduction?

A

the outer segment

336
Q

What is the composition of the rod outer segment?

A

1000 sacs/discs containing 1M rhodopsin molecules each

337
Q

What amount of light is required to active a rhodopsin molecule

A

a single photon is sufficient

338
Q

At what wavelength does rhodopsin best absorb light?

A

510nm

339
Q

What neurotransmitter is released from the synaptic terminal upon depolarization of a rod?

A

glutamate

340
Q

Does the rod outer segment contain mitochondria?

A

No, only the inner segment does. The outer segment performs glycolysis, but not oxidative metabolism.

341
Q

What is the flicker fusion frequency in cones?

A

100Hz in cones (30Hz in rods)

342
Q

How many spectral classes of cones are required to see color?

A

at least 2 classes

343
Q

What are the 3 types of cones in the human?

A

S, M, and L

344
Q

What is Nougaret disease?

A

the oldest known form of AD stationary nyctalopia, caused by a G38D mutation in rod transducin

345
Q

What causes Leber congenital amaurosis?

A

LCA (a childhood AR form of retinitis pigmentosa) is caused by null mutations of guanylate cyclase or homozygous defects of RPE 65

346
Q

What cuases gyrate atrophy?

A

homozygous defects of OAT (ornithine aminotransferase)

347
Q

What are the cells of the inner nuclear layer (INL)?

A

3 neuron types (bipolar, amacrine, horizontal) and 1 glial type (Muller cell)

348
Q

Do rods and cones share the same type of bipolar cells?

A

No, rods and cones have separate types of bipolar cells. Furthermore, there are cone on-bipolars and cone off-bipolars (for L and M cones), while there are only rod on-bipolars.

349
Q

What are the horizontal cells?

A

they are antagonistic interneurons that inhibit photoreceptors by releasing GABA when depolarized.

350
Q

What do amacrine cells do?

A

They mediate antagonistic interactions among on-bipolars, off-bipolars, and ganglion cells.

351
Q

What are the 2 main types of retinal ganglion cells?

A

On-center and off-center ganglion cells (based on their receptive fields)

352
Q

What are the 3 subgroups of retinal ganglion cells?

A

1) Tonic cells driven by L or M cones (project to parvocellular layers of LGN), 2) tonic cells driven by S cones, and 3) phasic cells (project to magnocellular layers of LGN)

353
Q

What makes up the ILM?

A

the end-feet of Muller (glial cells) of the retina (extend from photoreceptor inner segments to ILM)

354
Q

What is the RPE?

A

It is a single layer of cuboidal epithelial cells that constitutes the outermost layer of the retina

355
Q

Does the RPE contribute to the blood-retina barrier?

A

Yes, RPE cells are joind by tight junctions near their apical side (adjacent to the neurosensory retina)

356
Q

What are the physiologic roles of the RPE?

A

1) visual pigment regeneration, 2) phagocytosis of shed photoreceptor outer segment discs, 3) transport of necessary nutrients and ions to photoreceptor cells and removal of waste products from photoreceptors, 4) absorption of scattered and out of focus light via pigmentation, 5) adhesion of the retina

357
Q

What compound used in the formation of rhodopsin is generated by the RPE?

A

11-cis-retinaldehyde

358
Q

What are the 3 ways in which the RPE acquires vitamin A?

A

1) through release during bleaching of rhodopsin, 2) from circulation, 3) via phagocystosis of shed photoreceptor outer-segment discs

359
Q

How many outer-segment discs are shed per day by each photoreceptor?

A

100/day

360
Q

When does photoreceptor outer-segment disc shedding occur?

A

within 2 hrs of light onset for rods; at the onset of darkness for cones

361
Q

Is the fundus of an old person more or less pigmented than that of a young person?

A

The older person’s fundus is expected to be less pigmented, if everything else is held equal

362
Q

What factors contribute to the adhesion of the neurosensory retina to the RPE?

A

1) passive hydrostatic forces, 2) interdigitation of the outersegments and RPE microvilli, 3) active transport of subretinal fluid, 4) complex structure and binding properties of the interphotoreceptor matrix

363
Q

What are two old medication preservatives frequently implicated in ocular toxicity?

A

Thimerosal and benzalkonium chloride (BAK)

364
Q

What are two (currently) new medication preservatives that break down upon contact with the tear film to reduce corneal toxicity?

A

Oxychloro complex (Purite) – breaks down in presence of NaCl and H2O; Sodium perborate – breaks down in presence of hydrogen peroxide

365
Q

What percent of an eyedrop (50 microL) is actually retained in the tear lake of a patient?

A

at most 20% (10 microL)

366
Q

What is the half-life for tear lake turnover for an eye?

A

4 minutes (derived from rate of 16% turnover per minute)

367
Q

What factors affect the amount of a topically administered drug available for absorption?

A

1) Limited capacity of tear lake, 2) rate of tear lake turnover, 3) reflex tearing upon drug administration, 4) timing of subsequent med administration

368
Q

What is the “residence time” of a medication?

A

The amount of time that a drug remains in the tear reservoir and tear film

369
Q

What two patient actions can improve the delivery of a topical medication?

A

1) wait at least 5 minutes between administration of topical drops, 2) avoid blinking (to reduce the nasolacrimal pump mechanism) or apply punctal pressure for 5 minutes after administration

370
Q

How does systemic toxicity occur with topical medications?

A

Medication drains into the nasolacrimal duct and enters the nasopharynx, allowing absorption into systemic circulation via nasal mucosa

371
Q

What is a quick way to convert drug percentatge to mg/mL?

A

Add a power of ten (i.e., add a 0) to the drug percent (e.g. 1% –> 10 mg/mL)

372
Q

What is the permeability of the conj relative to the cornea for small water-soluble molecules?

A

20x that of the cornea

373
Q

What are the three stages that a medication needs to pass through to enter the AC through the cornea?

A

1) hydrophobic (epithelium cell membranes), 2) hydrophilic (stroma), 3) hydrophobic (endothelial cell membranes)

374
Q

What drug factors affect corneal penetration?

A

1) concentration, 2) solubility in delivery vehicle, 3) viscosity, 4) lipid solubility, 5) drug’s pH, ionic and steric form, 6) molecular size, 7) chemical structure and configuration, 8) vehicle, 9) surfactants, 10) amount of reflex tearing induced, 11) amount of binding to non-target tissue

375
Q

For what type of medications are subconjunctival, sub-Tenon, and retrobulbar injections particularly helpful?

A

For drugs with low lipid solubility (e.g. penicillin). These drugs would not penetrate the eye if given topically.

376
Q

Where are ACh receptors found in the somatic and autnomic nervous systems?

A

1) motor end plates of EOMs, levator, 2) superior cervical ganglion and ciliary and sphenopalatine ganlgia, 3) parasympathetic effector sites in iris sphincter and ciliary body, lacrimal, accessorry lacrimal, and meibomian glands

377
Q

What are the two subtypes of AChR?

A

Muscarinic and nicotinic

378
Q

What are the 3 types of action of cholinergic agents?

A

agonist, antagonist, and indirect agonist

379
Q

What are the 3 actions of topical direct cholinergic agonists?

A

1) miosis, 2) accommodation, 3) relative opening of TM, facilitating aq outflow

380
Q

What are the cholinergic agonists available?

A

1) Acetylcholine, 2) bethanechol, 3, carbachol, 4) pilocarpine

381
Q

What are the available reversible AChAse inhibitors?

A

1) Physostigmine, 2) neostigmine, 3) edrophonium

382
Q

What is the available irreversible AChAse inhibitors?

A

isoflurophate

383
Q

Does acetylcholine penetrate the cornea well?

A

No, it is usually given intracamerally

384
Q

What are side effects of muscarinic therapy?

A

1) miosis, 2) cataractogenesis, 3) induced myopia

385
Q

Is pralidoxime useful in ofrms of acetylcholinesterase inhibition caused by drugs other than organophosphates?

A

No, pralidoxime is only useful in organophosphate poisoning

386
Q

What are the actions of muscarinic antagonists?

A

1) paralysis of iris sphincter –> mydriasis, 2) cycloplegia (lack of accommodation), 3) reduction in iris-anterior capsule contact

387
Q

What is the oculocardiac reflex?

A

a reflex bradycardia elictied by manipulation of the conjunctiva, globe, or EOMs. Can be blocked by systemic administration of atropine or retrobulbar anesthesia.

388
Q

What are the systemic side effects of muscarinic antagonists?

A

flushing, fever, tachycardia, delirium

389
Q

What is the mechanism of action of edrophonium?

A

competitive inhibitor of acetylcholinesterase (reversibly binds to active site of AChAse)

390
Q

What is the effect of edrophonium in myasthenia gravis?

A

The inhibition of AChAse by edrophonium allows acetylcholine released into the synamptic cleft to accumulate to levels adequate to act through the reduced number of acetylcholine receptors.

391
Q

What can be co-administered with edrophonium to reduce side effects?

A

atropine 0.4-0.6mg IV, to reduce muscarinic receptor activation and leave only nicotinic receptor activation

392
Q

What are side effects of muscarinic antagonists?

A

blurred vision, confusion, mydriasis, constipation, urinary retention

393
Q

What are the two types of anti-nicotinic agents?

A

non-depolarizing and depolarizing agents

394
Q

Why should depolarizing nicotinic cholinergic receptor blockers be avoided in avoided in operatinos on lacerated eyes?

A

Depolarizing agents cause an initial depolarization and contraction that is temporary in most muscles. However, in the multiply innervated fibers of the EOMs (1/5 of fibers in EOMs), the depolarization and contraction is sustained. Contraction of the EOMs –> IOP increase –> expulsion of intraocular contents.

395
Q

Where are adrenergic receptors found in visual system?

A

1) cell membranes of iris dilator muscle, 2) Muller muscle, 3) ciliary epithelium and processes, 4) TM, smooth muscle of ocular blood vessels, 5) presynaptic terminals of some sympathetic and parasympathetic nerves

396
Q

What is the transmitter of most sympathetic postganglionic fibers?

A

norepinephrine

397
Q

What is the primary clinical use of direct-acting alpha-1 adrenergic agonists?

A

stimulation of iris dilator muscle to produce mydriasis

398
Q

In which patients is the elevatino in blood pressure due to alpha-1 agonists particularly significant?

A

patients with orthostatic hypotension and patients using drugs that accentuate adrenergic effects (reserpine, TCAs, cocaine, MAO inhibitors)

399
Q

What is the process by which testing to confirm and localize a sympathetic lesion affecting innervation of the iris dilator muscle is performed?

A

1) cocaine 4% given, pupil measured at 1 hr –> injured side has less accumulation of norepi, less dlation; 2) give hydroxyamphetamine (releases stored norepi), dilation => preganglionic, no dilation => postganglionic

400
Q

What is the mechanism of action of apraclinidine?

A

it is an alpha-2 agonist that prevents release of norepi at nerve terminals

401
Q

;What are the peak and trough IOP reduction of brimonidine tartrate?

A

26% and 14%, trough is less than that of nonselective beta blockers

402
Q

How do beta-2 agonists lower IOP?

A

reducing aqueous production, improving trabecular outflow, and increasing uveoscleral outflow

403
Q

How do beta antagonists lower IOP?

A

by reducing aqueous production by as much as 50%

404
Q

What are the 6 beta antagonists approved for the treatment of glaucoma?

A

1) betaxolol, 2) carteolol, 3) levobunolol, 4) metipranolol, 5) timolol maleate, 6) timolol hemihydrate

405
Q

Is the beta-1 selectivity in betaxolol absolute?

A

No, it is releative, and some beta-2 effect can remain

406
Q

What is a paradox associated with beta agonists and antagonists with regard to IOP?

A

Both beta agonists (e.g. dipivefrin) and beta antagonists can lower IOP. Furthermore, beta agonists and beta antagonists have slightly additive effects in lowering iOP

407
Q

Which part of the ciliary body secretes aqueous?

A

The nonpigmented epithelium of the ciliary processes

408
Q

On what physiologic function does ciliary body production of aqueous depend?

A

Na+ transport via Na/K/ATPase, which appears to be linked to HCO3 formation in the ciliary body

409
Q

What are the two portions of Na+ transport related to ciliary body production of aqueous?

A

Cl- related portion (60%) and HCO3- related portion (40%)

410
Q

What would potentially serve as a new class of aqueous production reducing drugs?

A

Drugs inhibiting the Cl- related portion of Na+ transport in the ciliary body

411
Q

How many times more carbonic anhydrase is present in the ciliary body and kidney than needed?

A

100x in the ciliary body and 1000x in the kidney

412
Q

What is a side effect of carbonic anhydrase inhibitors (and particularly acetazolamide, which is actively secreted into the renal tubules)?

A

metabolic acidosis

413
Q

Which CAIs are available in topical formulations?

A

dorzolamide (Trusopt) and brinzolamide (Azopt)

414
Q

What is the frequency of dosing of prostaglandin analogues?

A

qhs

415
Q

What are the side effects associated with prostaglandin analogues?

A

darkening of the iris and periocular skin (extent is positively correlated with degree baseline pigmentation), conjunctival hyperemai, hypertrhicosis or eyelashes, CME, uveitis

416
Q

What is an FDA restriction on combination medications?

A

That the combination be more efficacious than either component drug alone

417
Q

What are the two most common combination medications for IOP reduction?

A

Cosopt (timolol/dorzolamide) and Combigan (timolol/brimonidine)

418
Q

How do osmotic agents affect IOP?

A

Osmotic agents increase serum osmolarity –> fluid drawn out of eye across vascular barriers into vasculature –> IOP and vitreous volume decrease

419
Q

What are two uses of osmotic agents?

A

management of acute glaucoma, reduction of vitreous volume prior to cataract surgery

420
Q

Which osmotic agents are currently available for ophthalmic use in the US?

A

1) glycerin, 2) mannitol, 3) urea

421
Q

Why is urea rarely used as an osmotic agent?

A

It causes rebound elevation in IOP/vitreous volume, can cause tissue necrosis if it extravasates during administration

422
Q

What is a serious complication of mannitol and urea use as osmotic agents?

A

subarachnoid hemorrhage due to brain shrinkage and traction on subarachnoid vessels. The elderly are at increased risk for this complication

423
Q

What are the classes of ocular anti-inflammatory agents?

A

1) glucocorticoids, 2) NSAIDs, 3) mast-cell stabilizers, 4) antihistamines, 5) antifibrotics

424
Q

What are the effects of glucocorticoids at a tissue level?

A

suppress 1) local hyperthermia, 2) vascular congestion, 3) edema, 4) pain of inflammatory responses, 5) inflamatory tissue remodeling (capillary proliferation, fibroblast proliferation, colagen deposition, and scarring)

425
Q

Do glucocorticoids affect the afferent limb of immune response?

A

No, they primarily affect the efferent limb of immune response

426
Q

What are adverse effects of steroids in the eye?

A

1) glaucoma, 2) PSC cataracts, 3) exacerbation of infections, 4) ptosis, 5) mydriasis, 6) scleral melting, 7) eyelid skin atrophy

427
Q

Is ocular hypertension in response to steroids usually reproducible?

A

Yes

428
Q

What is the duration of steroid therapy required to develop steroid induced IOP elevation?

A

> 2 weeks

429
Q

What duration of steroid therapy can result in permanent elevations of IOP?

A

> 1 year

430
Q

Which two steroids have been developed to minimize IOP elevations?

A

1) rimexolone, 2) loteprednol etabonate

431
Q

What are the classes of NSAIDs?

A

1) salicylates, 2) indoles, 3) phenylalkanoic acids, 4) pyrazolones

432
Q

How is the anti-coagulative effect of aspirin mediated?

A

Irreversible inhibition of cycloxygenase, which prevents thromboxane formation in anucleate platelets

433
Q

What is the half-life of platelets and what is the duration of the anticoagulative effect of aspirin?

A

8-12 day half-life, 7-10 day duration of anti-coagulative effect of aspirin

434
Q

What is the frequency of dosing of ketorolac?

A

1 drop qid

435
Q

What are the corneal complications of topical NSAIDs?

A

corneal melting, corneal perforation

436
Q

How many mast cells are contained in the human eye?

A

50 million

437
Q

What is the mechanism of allergic conjunctivitis?

A

triggering antigens couple to reaginic antibodies (IgE on the cell surface of mast cells and basophils, leading to the release of histamine, PG, leukotrienes, and chemotactic factors from secretory granules

438
Q

What are the actions of histamine?

A

capillary dilation, increase in capillary permeability, nerve ending stimulation –> pain and itching

439
Q

Is lodoxamide superior to cromolyn sodium in treating vernal keratoconjunctivitis?

A

Yes

440
Q

What is a drawback of traditional mast cell stabilizers?

A

they take weeks to reach peak efficacy

441
Q

What is a dosing advantage of mitomycin C over 5-FU?

A

5-FU requires repeated postoperative injections when used in glaucoma filtering surgery, while mitomycin C requires only a single intraoperative application

442
Q

What are complications of mitomycin C application during glaucoma filtering surgery?

A

wound leakage, hypotony, localized sclearal melting

443
Q

What are the 5 classes of penicillins?

A

1) penicillin and phenethicillin, 2) PRSPs, 3) broad-spectrum penicillins (e.g. ampicillin, amoxicillin), 4) carbenicillin and ticarcillin (cover pseudomonas and enterobacter), 5) piperacillin, mezlocillin, and azlocillin (cover pseudomonas and klebsiella)

444
Q

How do 2nd generation cephalosporins differ from 1st generation cephalosporins?

A

The 2nd generation expand the activity against gram-negative organisms

445
Q

How do 3rd generation cephalosporins differ from 1st generation cephalosporins?

A

3rd generation cephalosporins provide expanded gram-negative coverage, but diminished gram-positive coverage. They do provide improved gram-positive coverage compared to 2nd generation cephalosporins, however.

446
Q

How do 4th generation cephalosporins differ from 3rd generation cephalosporins?

A

4th gen provide similar gram-negative coverage to 3rd gen (improved over 1st gen) and add anaerobic coverages

447
Q

What bacteria do all cephalosporins NOT cover?

A

enterococci, Listeria, Legionella, MRSA

448
Q

What are the commonly used ophthalmic fluoroquinolones?

A

ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin, ofloxacin

449
Q

What is the mechanism of action of fluoroquinolones?

A

Inhibition of DNA gyrase and topoisomerase IV

450
Q

How are sulfonamides specific to bacteria?

A

They affect the production of folic acid, which affects only those bacteria that must synthesize their own folic acid

451
Q

What is the overall incidence of adverse reactions to all sulfonamides?

A

5%

452
Q

What is the mechanism of action of tetracyclines?

A

inhibition of the 30S ribosomal subunit, preventing access of aminoacyl tRNA to the acceptor site on the mRNA-ribosome complex

453
Q

What is the mechanism of action of aminoglycosides?

A

binding to the 30S and 50S ribosomal subunits, interfering with initiation of protein synthesis

454
Q

What is the mechanism of action of vancomycin?

A

inhibition of glycopeptide polymerization in the cell wall

455
Q

Have topical or intraocular vancomycin been associated with ototoxicity or nephrotoxicity?

A

No, unlike systemic vancomycin

456
Q

What is the mechanism of action of macrolides?

A

binding to 50S subunit of bacterial ribosomes to interfere with protein synthesis

457
Q

What are the classes of antifungals?

A

1) polyenes (amphotericin, natamycin), 2) imidazoles (ketoconazole, miconazole), 3) triazoles (fluconazole and itraconazole), and 4) fluorinated pyrimidine (flucytosine)

458
Q

How is flucytosine primarily used?

A

as a PO adjunct to systemic amphotericin B therapy

459
Q

What are the 3 topical nucleotide analogues used to treat HSV keratitis?

A

idoxuridine, trifluidine, and vidarabine

460
Q

Is acyclovir available in the US as a topical formulation?

A

No, only IV and PO formulations are available in the US

461
Q

What are the 3 mechanisms by which acyclovir triphosphate (activated acyclovir) inhibits viral growth?

A

1) competitive inhibitor of DNA polymerase, 2) DNA chain terminator, 3) irreversible binding between viral DNA polymerase and interrupted chain, causing permanent inactivation of viral DNA polymerase

462
Q

Which medications can be used in thymidine kinase mutants?

A

vidarabine and foscarnet

463
Q

What are adverse effects of parenteral acyclovir?

A

renal toxicity (cyrstalline nephropathy) and neurotoxicity

464
Q

What is the recommended dosage of valacyclovir for HSV infections in immunocompetent individuals?

A

1g tid x7-14 days

465
Q

What is the mechanism of action of foscarnet?

A

inhibition of DNA polymerases, RNA polymerases, and reverse transcriptases

466
Q

What are the ocular side effects of cidofovir?

A

uveitis and hypotony

467
Q

In what form do the species of acanthamoeba involved in corneal infections exist?

A

as trophozoites or as double-walled cysts

468
Q

What is the first-line agent in the treatment of acanthamoeba keratitis?

A

polyhexamethylene biguanide (PHMB)

469
Q

What is the chemical form of local anesthetic agents used in ophthalmology?

A

tertiary amines linked by either 1) ester or 2) amide bonds to an aromatic residue

470
Q

Why are local anesthetics provided in the form of hycrochloride (HCl) salts?

A

the protonated forms of ophthalmic local anesthetics are more soluble and undergo hydrolysis more slowly in acidic solutions

471
Q

Why are unmyelinated fibers anesthetized more easily than myelinated fibers?

A

Only a small segment of an unmyelinated fiber must have sodium channels blocked to become anesthetized, as opposed to blocking sodium channels in multiple (separated) nodes in myelinated fibers

472
Q

Which type of local anesthetic (amide or ester) is preferred for retrobulbar blocks?

A

amide, due to their longer duration of action and lower systemic toxicity

473
Q

Is licodaine an amide or an ester?

A

amide

474
Q

What are the onset and duration of action for lidocaine as a retrobulbar or eyelid block?

A

5-minute onset, 1-2 hour duration of action

475
Q

Which nerves are the target of topical anesthetics for anterior segment surgery?

A

long and short ciliary, nasociliary, and lacrimal nerves

476
Q

What is the mechanism of action of botulinum toxin?

A

inhibition of release of acetylcholine at motor nerve terminals

477
Q

What are the active ingredients in artificial tear preparations?

A

polyvinyl alcohol, cellulose, methylcellulose, and their derivatives

478
Q

What is the frequency of dosing for topical cyclosporine (Restasis) for dry eye?

A

bid

479
Q

For what purpose are topical hyperosmolar agents used?

A

The treatment of corneal edema

480
Q

What does rose bengal highlight, and how does this differ from fluorescein?

A

Rose bengal highlights devitalized epithelial cells, while fluorescein outlines defects of the corneal or conjunctival epithelium

481
Q

For what uses has tPA been successfully applied in ophthalmology?

A

The resolution of fibrin clots after vitrectomy, keratoplasty, and glaucoma filtering procedures

482
Q

What drugs can be used to treat hemorrhage secondary to excessive fibrinolysis and to prevent recurrence of hyphema?

A

aminocaproic acid and tranexamic acid

Oftalmologia (15 decks)

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