Anatomy and Pathophysiology for ICD-10

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1 Anatomy and Pathophysiology for ICD-10 Module 10

2 Eye Anatomy

3 Functions of the Eye Task of the eye is to focus light originating from sources outside of the eye onto the retina The physical process at work to make this happen is called refraction Light crosses a boundary between two different things, in this case the atmosphere and the cornea A portion of its energy is reflected back into the atmosphere, but the remaining part is transmitted through the cornea into the interior of the eye As the transmitted portion of light passes through the corneal boundary it is refracted or bent Refraction is a critical process in eye function because it helps to aim light rays on the retina

4 Anatomy and Physiology Major Parts of the Eye Sclera Cornea Crystalline Choroid Vitreous Humor Retina Lens Fovea Iris/Pupil Macula Conjunctiva Ciliary Body

5 Sclera The sclera is the white of the eye Exterior is smooth and white Interior is brown and grooved Extremely durable Flexibility adds strength Continuous with sheath of optic nerve Tendons attached to it

6 Cornea The cornea is the clear bulging surface in front of the eye. It is the main refractive surface of the eye. Primary refractive surface of the eye Index of refraction: n = 1.37 Normally transparent and uniformly thick Nearly avascular Richly supplied with nerve fibers Sensitive to foreign bodies, cold air, chemical irritation Nutrition from aqueous humor Tears maintain oxygen exchange and water content Tears prevent scattering and improve optical quality

7 Cornea Phakic. If the patient still has their natural lens Aphakic. If the patients natural lens has been removed and there is no intraocular lens insertion Pseudophakic. If the patients natural lens has been removed and an intraocular lens inserted

8 Ophthalmology Anterior Chamber

9 Anterior Chamber The anterior chamber is between the cornea and the iris Aqueous humor is the fluid that fills the anterior chamber Produced by a structure alongside the lens called the ciliary body The aqueous passes first into the posterior chamber Then flows forward through the pupil into the anterior chamber of the eye

10 Ophthalmology Posterior Chamber

11 Posterior Chambers The posterior chamber is between the iris and the lens Contains the aqueous humor Index of refraction: n = 1.33 Specific viscosity of the aqueous just over 1.0 (like water, hence the name) Pressure of mm of mercury maintains shape of eye and spacing of the elements

12 Iris

13 Iris Iris is heavily pigmented The color of the iris is determined by the amount of pigment present in the iris structure No pigment at all results in a pink iris Increasing amounts of iris pigment produce green, hazel, and brown irises There actually are two pigments Melanin (brown) deposition is controlled by a gene on chromosome 15 Lipochrome (yellowish-brown) deposition is controlled by a gene on chromosome 19

14 Three Layers of the Iris From the front to the back Endothelium Thin layer of cells that lines the interior surface of blood vessels Stroma The connective, functionally supportive framework of a biological cell, tissue, or organ Epithelium Epithelial tissues line the cavities and surfaces of structures throughout the body, and also form many glands Functions of epithelial cells include secretion, selective absorption, protection, transcellular transport and detection of sensation

15 Pupil

16 Pupil In the middle of a normal iris is the pupil It is the hole through which light passes As the amount of light entering the eye diminishes Iris dilator muscle (which runs through the iris like spokes on a wheel) pulls away from the center, causing the pupil to dilate When too much light is entering the eye, the iris sphincter muscle (which encircles the pupil) pulls toward the center, causing the pupil to constrict Pupil diameter ranges from about 3-7 mm Area of 7-38 square mm (factor of 5)

17 Lens

18 Lens Transparent body enclosed in an elastic capsule Made up of proteins and water Consists of layers, like an onion, with firm nucleus, soft cortex Gradient refractive index ( ) Young person can change shape of the lens via ciliary muscles Contraction of muscle causes lens to bulge At roughly age 50, the lens can no longer change shape Becomes more yellow with age: Cataracts

19 Lens Vitreous Humor Fills the space between lens and retina Transparent gelatinous body Specific viscosity of (jelly-like consistency) Index of refraction, n=1.33 Nutrition from retinal vessels, ciliary body, aqueous Floaters, shadows of sloughed off material/debris in the vitreous Also maintains eye shape

20 Retina Light sensitive nerve tissue Converts images from the eye's optical system into electrical impulses that are sent along the optic nerve to the brain Forms a thin membranous lining of the rear two-thirds of the globe The retina is a complex, layered structure with several layers of neurons interconnected by synapses The only neurons that are directly sensitive to light are the photoreceptor cells

21 Retina These are mainly of two types of photoreceptor Rods Rods function mainly in dim light Provide black-and-white vision Cones Support daytime vision Provides perception of color A third, much rarer type of photoreceptor, the photosensitive to light, is important for reflexive responses to bright daylight

22 The Fovea Central pit in the macula that produces sharpest vision Contains a high concentration of cones and no retinal blood vessels There are only cones in the human fovea They are thinner, elongated, any very tightly packed The fovea is the location of highest visual acuity and best color vision

23 The Macula Small central area of the retina surrounding the fovea Small central area of the retina surrounding the fovea It has a diameter of around 5 mm Often histologically defined as having two or more layers of ganglion cells Ganglion cells are the final output neurons of the vertebrate retina Collect information about the visual world from bipolar cells and amacrine cells Most complex information processing systems in the vertebrate retina

24 Conjunctiva Image of a human eye clearly showing the blood vessels of the conjunctiva

25 Conjunctiva The conjunctiva is a clear mucous membrane consisting of cells and underlying basement membrane that covers the sclera The conjunctiva is typically divided into three parts: Palpebral or tarsal conjunctiva Lines the eyelids Bulbar or ocular conjunctiva Covers the eyeball, over the sclera. This region of the conjunctiva is tightly bound to the underlying sclera by Tenon s capsule and moves with the eyeball movements Fornix conjunctiva Forms the junction between the bulbar and palpebral conjunctivas. It is loose and flexible, allowing the free movement of the lids and eyeball.

26 Conjunctiva Functions It helps lubricate the eye by producing mucous and tears Contributes to immune surveillance Helps to prevent the entrance of microbes into the eye

27 Choroid Vascular (major blood vessel) layer of the eye lying between the retina and the sclera The human choroid is thickest at the far extreme Rear of the eye (at 0.2 mm), while in the outlying areas it narrrws to 0.1 mm The choroid provides oxygen and nourishment to the outer layers of the retina Along with the ciliary body and iris, the choroid forms the uveal tract Also called the uveal layer, uveal coat, or vascular tunic, is the pigmented middle of the three concentric layers that make up an eye

28 Ophthalmologic Disease, Conditions and Treatments

29 Diseases and Disorders Bullous Keratopathy

30 Bullous Keratopathy of Cornea A pathological condition in which small vesicles, or bullae, are formed in the cornea due to endothelial dysfunction The corneal endothelial cells normally do not undergo mitotic cell division, and cell loss results in permanent loss of function. endothelial cell counts drop too low, the pump starts failing to function and fluid moves anterior into the stroma and epithelium. The excess fluid precipitates swelling of the cornea. As fluid accumulates between the basal epithelium cells, blister like formations form (bullae) and they undergo painful ruptures releasing their fluid content to the surface.

31 Fuchs Endothelial Dystrophy (FED) of Cornea A degenerative disorder of the corneal endothelium with accumulation of focal excrescences called guttae and thickening of Descemet s membrane, leading to corneal edema and loss of vision. Corneal endothelial cells are the major pump cells of the cornea to allow for stromal clarity. In FED, Descemet s membrane is grossly thickened with accumulation of abnormal wide-spaced collagen and numerous guttae. Corneal endothelial cells in end-stage FED are reduced in number and appear attenuated, causing progressive stromal edema.

32 Fuchs Endothelial Dystrophy (FED) of Cornea Progressive endothelial cell loss causes relative influx of aqueous humor into the cornea, leading to swelling (corneal stromal edema), which results in distorted vision. Eventually, the epithelium also becomes edematous, resulting in more severe visual impairment. Focal areas or blisters of epithelial edema ("bullae") may be particularly painful.

33 Treatment of the Cornea Phototherapeutic keratectomy (PTK) Uses an excimer laser to vaporize thin layers of diseased cornea. PTK is used as an alternative to keratoplasty for patients with corneal dystrophies, corneal scars and certain corneal infections. Keratoplasty, also known as a corneal transplant or a corneal graft Involves removing damaged or diseased cornea and replacing it with clear corneal tissue from a donor. If all layers of the cornea are replaced, it is called penetrating or full thickness. If only the outer layers of the cornea are replaced, it is called lamellar or partial thickness.

34 Treatment of the Cornea Keratoplasty (corneal transplant); lamellar Technically more difficult than a full thickness excision of the cornea Partial thickness technique, meaning that only the diseased outer layers of the cornea are removed, preserving the deeper layers of the cornea Donor corneal transplant tissue is placed over the resulting defect. Since the deeper layers of the patients cornea are preserved, the risk of infection or tissue rejection may be greatly reduced Useful for the treatment of a thinning or irregularly shaped cornea, or when corneal changes are limited to the anterior (outer) layers of the cornea Usually restore good vision, although the resulting visual acuity may be less than with full-thickness (penetrating) keratoplasty

35 Treatment of the Cornea Penetrating or full thickness, keratoplasty Involves removal of corneal tissue and replacement with donor graft tissue. Full thickness removal of the diseased cornea. Healthy peripheral corneal tissue is left intact. Donor corneal tissue is cut to fit the resulting defect and the graft is sutured to the patients remaining healthy cornea. Will often restore good visual acuity Common indications for penetrating keratoplasty Keratoconus, corneal transplant tissue rejection, corneal degeneration, corneal scarring, keratitis, and bullous keratopathy. As with lamellar keratoplasty, penetrating keratoplasty.

36 Age-Related Macular Degeneration (AMD) Disease associated with aging that gradually destroys sharp, central vision Central vision is needed for seeing objects clearly and for common daily tasks such as reading and driving AMD affects the macula, the part of the eye that allows you to see fine detail AMD advances so slowly that people notice little change in their vision AMD is a leading cause of vision loss in Americans 60 years of age and older AMD occurs in two forms: wet and dry

37 Age-Related Macular Degeneration (AMD) The blood and fluid raise the macula from its normal place at the back of the eye Damage to the macula occurs rapidly Loss of central vision can occur quickly Also known as advanced AMD An early symptom of wet AMD is that straight lines appear wavy

38 Types of Age-Related Macular Degeneration (AMD) Wet AMD Occurs when abnormal blood vessels behind the retina start to grow under the macula These new blood vessels tend to be very fragile and often leak blood and fluid The blood and fluid raise the macula from its normal place at the back of the eye Damage to the macula occurs rapidly Loss of central vision can occur quickly Also known as advanced AMD An early symptom of wet AMD is that straight lines appear wavy

39 Types of Age-Related Macular Degeneration (AMD) Dry AMD The combined weight of the adrenal glands in an adult human ranges from 7 to 10 grams. Dry AMD occurs when the light-sensitive cells in the macula slowly break down, gradually blurring central vision in the affected eye You may see a blurred spot in the center of your vision Central vision is gradually lost in the affected eye Dry AMD generally affects both eyes, but vision can be lost in one eye while the other eye seems unaffected

40 Risk of Age-Related Macular Degeneration (AMD) Smoking Smoking may increase the risk of AMD. Obesity Research studies suggest a link between obesity and the progression of early and intermediate stage AMD to advanced AMD. Race Whites are much more likely to lose vision from AMD than African Americans AMD Family History Those with immediate family members who have AMD are at a higher risk of developing the disease Gender. Women appear to be at greater risk than men

41 AMD Symptoms Both dry and wet AMD cause no pain For dry AMD: the most common early sign is blurred vision Often this blurred vision will go away in brighter light For wet AMD: the classic early symptom is that straight lines appear crooked A small blind spot may also appear

42 Treatment of Wet AMD Laser surgery Photodynamic therapy Injections into the eye The disease and loss of vision may progress despite treatment Laser surgery. This procedure uses a laser to destroy the fragile, leaky blood vessels. A high energy beam of light is aimed directly onto the new blood vessels and destroys them, preventing further loss of vision Photodynamic therapy. A drug called verteporfin is injected into your arm. It travels throughout the body, including the new blood vessels in your eye. The drug tends to "stick" to the surface of new blood vessels.

43 Diseases and Disorders Treatment of wet AMD Injections. Wet AMD can now be treated with new drugs that are injected into the eye (anti-vegf therapy). Abnormally high levels of a specific growth factor occur in eyes with wet AMD and promote the growth of abnormal new blood vessels. This drug treatment blocks the effects of the growth factor and diminished production of thyroid hormone Treatment of dry AMD Once dry AMD reaches the advanced stage, no form of treatment can prevent vision loss

44 Diseases and Disorders Amblyopia

45 Amblyopia Amblyopia is the medical term used when the vision in one of the eyes is reduced because the eye and the brain are not working together properly Amblyopia is the most common cause of visual impairment in childhood The condition affects approximately 2 to 3 out of every 100 children It is the most common cause of monocular (one eye) visual impairment among children and young and middle-aged adults This condition is also sometimes called lazy eye

46 Causes of Amblyopia Amblyopia may be caused by any condition that affects normal visual development or use of the eyes Amblyopia can be caused by strabismus Strabismus can be either a disorder of the brain in coordinating the eyes, or of one or more of the relevant muscles' power or direction of motion Sometimes amblyopia is caused when one eye is more nearsighted, farsighted, or astigmatic than the other eye

47 Treatment for Amblyopia Making the child use the eye with the reduced vision (weaker eye). Currently, there are two ways used to do this Atropine A drop of a drug called atropine is placed in the stronger eye once a day to temporarily blur the vision so that the child will prefer to use the eye with amblyopia Stimulates vision in the weaker eye and helps the part of the brain that manages vision develop more completely Patching An opaque, adhesive patch is worn over the stronger eye for weeks to months Patching stimulates vision in the weaker eye and helps the part of the brain that manages vision develop more completely

48 Diseases and Disorders Astigmatism

49 Astigmatism It is a condition in which the eye does not focus light evenly onto the retina, the light-sensitive tissue at the back of the eye Common type of refractive error Refraction is the bending of light as it passes through one object to another Vision occurs when light rays are bent (refracted) as they pass through the cornea and the lens. The light is then focused on the retina The retina converts the light-rays into messages that are sent through the optic nerve to the brain. The brain interprets these messages into the images we see

50 Symptoms & Treatments of Astigmatism Symptoms Headaches, Eyestrain Squinting, Distorted or blurred vision at all distances, Difficulty driving at night Treatment Eyeglasses Simplest and safest way to correct astigmatism Contact Lenses provide clearer vision, a wider field of vision, and greater comfort Refractive Surgery Aims to change the shape of the cornea permanently

51 Diseases and Disorders Cataract

52 Cataract Clouding of the crystalline lens in the eye that affects vision Cataracts are very common in older people A cataract can occur in either or both eyes Most cataracts are related to aging, there are other types of cataract: Secondary cataract- Cataracts can form after surgery for other eye problems, such as glaucoma Traumatic cataract- Cataracts can develop after an eye injury, sometimes years later Congenital cataract- Some babies are born with cataracts or develop them in childhood, often in both eyes. These cataracts may be so small that they do not affect vision. If they do, the lenses may need to be removed

53 Causes and Risks for Cataract Causes Researchers suspect that there are several causes of cataract» Smoking» Diabetes» The protein in the lens just changes from the wear and tear it takes over the years» The environment such as prolonged exposure to sunlight

54 Symptoms of Cataract Cloudy or blurry vision. Colors seem faded. Glare. Headlights, lamps, or sunlight may appear too bright. A halo may appear around lights. Poor night vision. Double vision or multiple images in one eye. (This symptom may clear as the cataract gets larger.) Frequent prescription changes in your eyeglasses or contact lens

55 Treatment of Cataract Removing the diseased lens is the only way to correct a cataract. There are two distinct methods of cataract extraction intracapsular and extracapsular. Intracapsular extraction involves removing the entire lens including the capsule that surrounds the lens. Extracapsular extraction involves cutting a hole in the front of the capsule, breaking up the lens and then removing the fragments. After the lens is removed, ophthalmologists commonly insert an intraocular lens prosthesis (IOL) to replace some of the lens function.

56 Disease and Disorders Glaucoma Normal Vision Glaucoma Vision

57 Glaucoma Group of diseases that can damage the eye's optic nerve and result in vision loss and blindness Normal fluid pressure inside the eyes slowly rises Forms of glaucoma Low-tension or normal-tension glaucoma Angle-closure glaucoma Congenital glaucoma Secondary glaucoma

58 Risk for Glaucoma African Americans over age 50. Five times more likely to occur in African Americans than in Caucasians. About four times more likely to cause blindness in African Americans than in Caucasians. Fifteen times more likely to cause blindness in African Americans between the ages of than in Caucasians of the same age group Everyone over age 65, especially Hispanic Americans. People with a family history of glaucoma

59 Treatment for Glaucoma Trabeculoplasty relieves a patients high intraocular pressure with a laser. The physician burns holes in the trabecular meshwork in order to improve the drainage of fluid in the anterior segment. Improving drainage acts to lower intraocular pressure. The physician treats small areas during each session so that the results can be monitored until the desired pressure is reached. This procedure usually requires multiple treatments. Trabeculectomy relieves a patients high intraocular pressure with an incisional procedure. The physician makes a limbal incision and removes a partial-thickness wedge of the trabecular meshwork to improve the drainage of fluid. At the same time, the surgeon creates an angled channel in the sclera ending with a bleb in the conjunctiva. The bleb acts as a pressure valve for fluid drainage. An antifibrotic solution may be injected into the bleb to keep it from healing and closing.

60 Treatment for Glaucoma Scleral fistulization through ciliary body or Transciliary filtration (TCF) for glaucoma relieves high intraocular pressure in phakic primary open-angle patients with a special blade made of plasma particles. The plasma particles surround a filament as thin as human hair and ablate the sclera and underlying ciliary body to improve the drainage of intraocular fluid from behind the iris. This device creates a tiny opening called a micropore with clean margins and does no damage to surrounding tissue, minimizing both the recovery time and the risk of scarring. Also, since the micropore is so small, no scleral flap or bleb is needed.

61 Hyperopia Farsightedness, is a common type of refractive error where distant objects If there is significant hyperopia, vision can be blurry for objects at any distance, near or far Causes Develops in eyes that focus images behind the retina instead of on the retina Occurs when the eyeball is too short Abnormal shape of the cornea or lens Symptoms Headaches Eyestrain Squinting Blurry vision, especially for close objects

62 Disease and Disorders of Myopia

63 Myopia Nearsightedness Common type of refractive error where close objects appear clearly, but distant objects appear blurry Can affect both children and adults Condition affects about 25 percent of Americans Symptoms Headaches Eyestrain Squinting Difficulty seeing distant objects Treatment Eyeglasses Contact lenses Surgery

64 Disease and Disorders of Retinopathy

65 Diabetic Retinopathy Most common diabetic eye disease and a leading cause of blindness in American adults Progressive disease that damages vessels in the back of the eye. Patients who have been diabetic for a long time and/or those who have poor control of blood sugar levels are more likely to develop diabetic retinopathy. Common symptoms Blurred vision, decreased vision, flashes and floaters, and vision loss. Individuals with early retinopathy may not experience any symptoms.

66 Types of Diabetic Retinopathy Background diabetic retinopathy (BDR) Occurs when the diabetes causes dilation and leaking in the retinal arteries, forming small hemorrhages and fluid accumulation. This leads to retinal edema and swelling that distorts and decreases the patients vision Nonproliferative diabetic retinopathy (NPDR) The earliest phase of the disease and is characterized by retinal vascular abnormalities including microaneurysms, intraretinal hemorrhages, and cotton-wool spots (small areas of yellowish-white coloration in the retina). As diabetic retinopathy progresses, there is a gradual closure of retinal vessels, which results in impaired perfusion and retinal ischemia. Signs of increasing ischemia include venous abnormalities and more severe vascular leakage. When these signs progress past certain levels, moderate or severe nonproliferative diabetic retinopathy is diagnosed.

67 Types of Diabetic Retinopathy Proliferative diabetic retinopathy (PDR) The later and more serious phase of the disease. Diabetes causes the retinal vessels to become ischemic, depriving the retina of oxygen and encouraging tiny new vessels to form to increase oxygenization (also called neovascularization). The new vessels are fragile and often rupture, causing retinal and vitreous hemorrhages that distort and decrease vision and create floaters.

68 Nonproliferative Stages of Diabetic Retinopathy Three Stages Mild Nonproliferative Retinopathy Earliest stage Moderate Nonproliferative Retinopathy Some blood vessels that nourish the retina are blocked Severe Nonproliferative Retinopathy Many more blood vessels are blocked, depriving several areas of the retina with their blood supply

69 Diabetic Macular Edema Swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the macula that only occurs with diabetic retinopathy. As macular edema develops, blurring develops in the middle or just to the side of the central visual field. Visual loss from diabetic macular edema can progress over a period of months and make it impossible to focus clearly.

70 Treatment for Diabetic Retinopathy Radiology: Fluorescein Angiography Fundus Photography Ophthalmoscopy Associated Pathology: Retinal detachment Retinal tears Vitreous hemorrhage

71 Treatment for Diabetic Retinopathy Medications: Insulin Alpha-glucose inhibitors (Glyset, Precose) Biguanides (Glucophage, Glucovance) Meglitinides (Prandin) Sulfonylureas (Diabeta, Micronase) Thiazolidinediones (Actos, Avandia)

72 Treatment for Diabetic Retinopathy Focal Laser Laser treatment for background retinopathy that seals the leaking blood vessels. It involves targeting specific retinal locations with a relatively small number of burns. Pan-Retinal Photocoagulation (PRP laser) Laser treatment for proliferative retinopathy that removes ischemic vessels to stop neovascularization and prevent further new vessel growth. It involves burning a large patch of the retinal with frequent burns. Vitrectomy Removal of blood-stained vitreous from the back of the eye by inserting a cannula into the vitreous and suctioning it out. The vitreous is replaced by a clear vitreous substitute that re-establishes the proper pressure in the eye. In many cases, inserting this fluid causes enough pressure to gently press the retina back into place, allowing it to re-attach.

73 Ophthalmology Usher Syndrome

74 Usher Syndrome Also known as pigmentary retina dystrophy Most common condition that affects both hearing and vision As it progresses, the field of vision narrows, a condition known as "tunnel vision," until only central vision (the ability to see straight ahead) remains

75 Causes of Usher Syndrome Inherited through genes Inherited as an autosomal recessive trait Autosomal means that the mutated gene is not located on either of the chromosomes that determine a person's sex; in other words, both males and females can have the disorder and can pass along the disorder to a child

76 Symptoms and Treatment of Usher Syndrome Causes night-blindness and a loss of peripheral vision Major symptom are hearing loss and an eye disorder called retinitis pigmentosa Tunnel vision Treatment There is no cure Vitamin A palmitate may slow, but not halt, the progression of retinitis pigmentosa

77 Vitreous Floater

78 Vitreous Floaters Also known as vitreous opacities Specks that float about in your field of vision Small, dark, shadowy shapes that can look like spots, threadlike strands, or squiggly lines They do not follow your eye movements Usually drift when your eyes stop moving

79 Causes of Vitreous Floaters When the vitreous, a gel-like substance that fills about 80 percent of the eye and helps it maintain a round shape, slowly shrinks Becomes somewhat stringy, and the strands can cast tiny shadows on the retina called floaters Part of the natural aging process More common in people who are very nearsighted Have diabetes, or who have had a cataract operation

80 Treatment for Vitreous Floaters For people who have floaters that are simply annoying, no treatment is recommended Floaters can be so dense and numerous that they significantly affect vision Vitrectomy, a microsurgical procedure for removing an opacity (usually consisting of old blood and protein) from the vitreous cavity of the eye Removes the vitreous gel, along with its floating debris, from the eye

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