2019-2020 Basic and Clinical Science Course, Section 02: Fundamentals and Principles of Ophthalmology

569 Pages·2019·99.604 MB·English

by  American Academy of Ophthalmology, Vikram S. Brar MD (editor)

22
Fundamentals and Principles
of Ophthalmology
2019–2020
(cid:2)BCSC
Basic and Clinical
Science Course™
Published after collaborative
review with the European Board
of Ophthalmology subcommittee
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The American Academy of Ophthalmology is accredited by the Accreditation Council for Con-
tinuing Medical Education (ACCME) to provide continuing medical education for physicians.
The American Academy of Ophthalmology designates this enduring material for a maximum of
15 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with
the extent of their participation in the activity.
CME expiration date: June 1, 2022. AMA PRA Category 1 Credits™ may be claimed only once be-
tween June 1, 2019, and the expiration date.
BCSC® volumes are designed to increase the physician’s ophthalmic knowledge through study and
review. Users of this activity are encouraged to read the text and then answer the study questions
provided at the back of the book.
To claim AMA PRA Category 1 Credits™ upon completion of this activity, learners must demon-
strate appropriate knowledge and participation in the activity by taking the posttest for Section 2
and achieving a score of 80% or higher. For further details, please see the instructions for requesting
CME credit at the back of the book.
The Academy provides this material for educational purposes only. It is not intended to represent the
only or best method or procedure in every case, nor to replace a physician’s own judgment or give
specific advice for case management. Including all indications, contraindications, side effects, and
alternative agents for each drug or treatment is beyond the scope of this material. All information and
recommendations should be verified, prior to use, with current information included in the manufac-
turers’ package inserts or other independent sources, and considered in light of the patient’s condition
and history. Reference to certain drugs, instruments, and other products in this course is made for
illustrative purposes only and is not intended to constitute an endorsement of such. Some material
may include information on applications that are not considered community standard, that reflect
indications not included in approved FDA labeling, or that are approved for use only in restricted
research settings. The FDA has stated that it is the responsibility of the physician to determine
the FDA status of each drug or device he or she wishes to use, and to use them with appropriate,
informed patient consent in compliance with applicable law. The Academy specifically disclaims
any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and
all claims that may arise from the use of any recommendations or other information contained herein.
All trademarks, trade names, logos, brand names, and service marks of the American Academy of
Ophthalmology (AAO), whether registered or unregistered, are the property of AAO and are pro-
tected by US and international trademark laws. These trademarks include AAO; AAOE; AMERICAN
ACADEMY OF OPHTHALMOLOGY; BASIC AND CLINICAL SCIENCE COURSE; BCSC; EYENET;
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NETWORK; OPHTHALMOLOGY; OPHTHALMOLOGY GLAUCOMA; OPHTHALMOLOGY
RETINA; PREFERRED PRACTICE PATTERN; PROTECTING SIGHT. EMPOWERING LIVES;
and THE OPHTHALMIC NEWS & EDUCATION NETWORK.
Cover image: From BCSC Section 9, Uveitis and Ocular Inflammation. Large mutton-fat keratic precipi-
tates in a patient with sarcoidosis. (Courtesy of Debra Goldstein, MD.)
Copyright © 2019 American Academy of Ophthalmology. All rights reserved. No part of
this publication may be reproduced without written permission.
Printed in China.
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Basic and Clinical Science Course
Louis B. Cantor, MD, Indianapolis, Indiana, Se nior Secretary for Clinical
Education
Christopher J. Rapuano, MD, Philadelphia, Pennsylvania, Secretary for
Lifelong Learning and Assessment
Colin A. McCannel, MD, Los Angeles, California, BCSC Course Chair
Section 2
Faculty for the Major Revision
Vikram S. Brar, MD, Chair, Richmond, Virginia
Simon K. Law, MD, Los Angeles, California
Jennifer L. Lindsey, MD, Nashville, Tennessee
David A. Mackey, MD, Perth, Western Australia
Robert L. Schultze, MD, Slingerlands, New York
Evan Silverstein, MD, Richmond, Virginia
Ravi S. J. Singh, MD, Shawnee Mission, Kansas
The Acad emy wishes to acknowledge the following committees for review of this edition:
Committee on Aging: Elliot H. Sohn, MD, Iowa City, Iowa
Vision Rehabilitation Committee: Mona A. Kaleem, MD, Ellicott City, Mary land
Practicing Ophthalmologists Advisory Committee for Education: Bradley D. Fouraker, MD,
Primary Reviewer and Chair, Tampa, Florida; Alice Bashinsky, MD, Asheville, North Car-
olina; David J. Browning, MD, PhD, Charlotte, North Carolina; Cynthia S. Chiu, MD,
Oakland, California; Steven J. Grosser, MD, Golden Valley, Minnesota; Stephen R. K lapper,
MD, Carmel, Indiana; Troy M. Tanji, MD, Waipahu, Hawaii; Michelle S. Ying, MD, MSPH,
Ladson, South Carolina
The Acade my also wishes to acknowledge the following committee for assistance in devel-
oping Study Questions and Answers for this BCSC Section:
Self- Assessment Committee: Deepa Abraham, MD, Seattle, Washington; William R.
Barlow, MD, Salt Lake City, Utah; William L. Becker, MD, St Louis, Missouri; Michele
M. Bloomer, MD, San Francisco, California; John J. Chen, MD, PhD, Rochester, Minne-
sota; Zelia M. Correa, MD, Baltimore, Maryland; Deborah M. Costakos, MD, Milwaukee,
Wisconsin; Theodore Curtis, MD, Mount Kisco, New York; Laura C. Fine, MD, Boston,
Mas sa chu setts; Robert E. Fintelmann, MD, Phoenix, Arizona; Jeffrey M. Goshe, MD, Cleve-
land, Ohio; Mark Greiner, MD, Iowa City, Iowa; Paul B. Griggs, MD, Seattle, Washing-
ton; David R. Hardten, MD, Minnetonka, Minnesota; Rachel M. Huckfeldt, MD, Boston,
Mas sa chu setts; Sarah S. Khodadadeh, MD, Vero Beach, Florida; Douglas R. Lazzaro, MD,
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Brooklyn, New York; Amanda C. Maltry, MD, Minneapolis, Minnesota; Brian Privett, MD,
Cedar Rapids, Iowa; Sunita Radhakrishnan, MD, San Mateo, California; Jordan J. Rixen,
MD, Lincoln, Nebraska; Mark I. Salevitz, MD, Scottsdale, Arizona; Ravi S. J. Singh, MD,
Shawnee Mission, Kansas; Mitchell B. Strominger, MD, Reno, Nevada; Janet Y. Tsui, MD,
Santa Clara, California; Ari L. Weitzner, MD, New York, New York; Zoë R. Williams, MD,
Rochester, New York; Kimberly M. Winges, MD, Portland, Oregon
Eu ro pean Board of Ophthalmology: Peter J. Ringens, MD, PhD, EBO Chair for BCSC
Section 2 and EBO- BCSC Program Liaison, Maastricht, Netherlands
Financial Disclosures
Acad emy staff members who contributed to the development of this product state that
within the 12 months prior to their contributions to this CME activity and for the dura-
tion of development, they have had no financial interest in or other relationship with any
entity discussed in this course that produces, markets, resells, or distributes ophthalmic
health care goods or ser vices consumed by or used in patients, or with any competing
commercial product or ser vice.
The authors and reviewers state that within the 12 months prior to their contributions
to this CME activity and for the duration of development, they have had the following
financial relationships:*
Dr Browning: Aerpio Therapeutics (S), Alcon Laboratories (S), Alimera Sciences (C),
Emmes (S), Genentech (S), Novartis Phar ma ceu ti cals (S), Ohr Phar ma ceu ti cals (S), Pfizer
(S), Regeneron Phar ma ceu ti cals (S), Springer (P), Zeiss (O)
Dr Correa: Castle Biosciences (C)
Dr Fintelmann: Alphaeon (O), Strathspey Crown (O)
Dr Fouraker: Addition Technology (C, L), Alcon Laboratories (C, L), OASIS Medical
(C, L)
Dr Goshe: Carl Zeiss Meditec (L)
Dr Grosser: InjectSense (O), Ivantis (O)
Dr Hardten: Allergan (C, L, S), Avedro (C), Eye Surgical Instruments (C, O), Johnson &
Johnson (C), Oculus (L), Optical Systems Design (C, O), TLC Vision (C)
Dr Huckfeldt: AGTC (S), MeiraGTx (S), Spark Therapeutics (S)
Dr Klapper: AdOM Advanced Optical Technologies (O)
Dr Privett: Omeros (O)
Dr Radhakrishnan: Netra Systems (C, O)
Dr Schultze: Alcon Laboratories (L), Bausch + Lomb Surgical (L), Novartis Alcon Phar-
ma ceu ti cals (L), Sun Phar ma ceu ti cals (L)
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Dr Silverstein: I- See Vision Technology (O); Welch Allyn (C)
Dr Sohn: GlaxoSmithKline (S), Oxford Biomedical (S), Regeneron (S), Sanofi Fovea (S)
The other authors and reviewers state that within the past 12 months prior to their contri-
butions to this CME activity and for the duration of development, they have had no finan-
cial interest in or other relationship with any entity discussed in this course that produces,
markets, resells, or distributes ophthalmic health care goods or ser vices consumed by or
used in patients, or with any competing commercial product or ser vice.
*C = con sul tant fees, paid advisory boards, or fees for attending a meeting; L = lecture fees (honoraria),
travel fees, or reimbursements when speaking at the invitation of a commercial sponsor; O = equity own-
ership/stock options of publicly or privately traded firms (excluding mutual funds) with manufacturers
of commercial ophthalmic products or commercial ophthalmic ser vices; P = patents and/or royalties that
might be viewed as creating a potential conflict of interest; S = grant support for the past year (all sources)
and all sources used for a specific talk or manuscript with no time limitation
Recent Past Faculty
Michael H. Goldstein, MD
Alon Kahana, MD, PhD
William R. Katowitz, MD
Lawrence M. Levine, MD
In addition, the Acad emy gratefully acknowledges the contributions of numerous past
faculty and advisory committee members who have played an impor tant role in the devel-
opment of previous editions of the Basic and Clinical Science Course.
American Acade my of Ophthalmology Staff
Dale E. Fajardo, EdD, MBA, Vice President, Education
Beth Wilson, Director, Continuing Professional Development
Ann McGuire, Acquisitions and Development Man ag er
Stephanie Tanaka, Publications Man ag er
Susan Malloy, Acquisitions Editor and Program Man ag er
Jasmine Chen, Man ag er of E- Learning
Beth Collins, Medical Editor
Eric Gerdes, Interactive Designer
Naomi Ruiz, Publications Specialist
Debra Marchi, Permissions Assistant
American Acad emy of Ophthalmology
655 Beach Street
Box 7424
San Francisco, CA 94120-7424
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Contents
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . xvii
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PART I Anatomy 3
. . . . . . . . . . . . . . . . . . . . . . . . . .
1 Orbit and Ocular Adnexa . . . . . . . . . . . . . . . . . . . 5
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Orbital Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Dimensions of the Adult Orbit . . . . . . . . . . . . . . . . . . . 5
Bony Orbit . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Orbital Margin . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Orbital Roof . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Medial Orbital Wall . . . . . . . . . . . . . . . . . . . . . . . . 8
Orbital Floor . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Lateral Orbital Wall . . . . . . . . . . . . . . . . . . . . . . . 10
Orbital Foramina, Ducts, Canals, and Fissures . . . . . . . . . . . 10
Periorbital Sinuses . . . . . . . . . . . . . . . . . . . . . . . 12
Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Ciliary Ganglion . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Branches of the Ciliary Ganglion . . . . . . . . . . . . . . . . . 15
Short Ciliary Nerves. . . . . . . . . . . . . . . . . . . . . . . 16
Extraocular Muscles . . . . . . . . . . . . . . . . . . . . . . . . . 17
Extraocular Muscle Origins . . . . . . . . . . . . . . . . . . . . 18
Extraocular Muscle Insertions . . . . . . . . . . . . . . . . . . 20
Extraocular Muscle Distribution in the Orbit . . . . . . . . . . . . 20
Blood Supply to the Extraocular Muscles . . . . . . . . . . . . . . 21
Innervation of the Extraocular Muscles . . . . . . . . . . . . . . 21
Fine Structure of the Extraocular Muscles . . . . . . . . . . . . . 22
Vascular Supply and Drainage of the Orbit . . . . . . . . . . . . . . . 22
Posterior and Anterior Ciliary Arteries. . . . . . . . . . . . . . . 22
Vortex Veins . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Eyelids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Vascular Supply of the Eyelids . . . . . . . . . . . . . . . . . . 37
Lymphatics of the Eyelids . . . . . . . . . . . . . . . . . . . . 38
Lacrimal Glands and Excretory System . . . . . . . . . . . . . . . . 39
Lacrimal Gland . . . . . . . . . . . . . . . . . . . . . . . . . 39
Accessory Glands . . . . . . . . . . . . . . . . . . . . . . . . 41
Lacrimal Excretory System . . . . . . . . . . . . . . . . . . . . 42
vii
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viii (cid:2) Contents
Conjunctiva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Caruncle. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Plica Semilunaris . . . . . . . . . . . . . . . . . . . . . . . . 44
Tenon Capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2 The Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Topographic Features of the Globe . . . . . . . . . . . . . . . . . . 48
Precorneal Tear Film . . . . . . . . . . . . . . . . . . . . . . . . 49
Cornea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Characteristics of the Central and Peripheral Cornea. . . . . . . . . 51
Epithelium and Basal Lamina . . . . . . . . . . . . . . . . . . . 51
Bowman Layer . . . . . . . . . . . . . . . . . . . . . . . . . 51
Stroma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Descemet Membrane . . . . . . . . . . . . . . . . . . . . . . 53
Endothelium . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Limbus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Sclera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Anterior Chamber . . . . . . . . . . . . . . . . . . . . . . . . . 59
Trabecular Meshwork . . . . . . . . . . . . . . . . . . . . . . . . 63
Uveal Trabecular Meshwork . . . . . . . . . . . . . . . . . . . 63
Corneoscleral Meshwork. . . . . . . . . . . . . . . . . . . . . 63
Juxtacanalicular Meshwork . . . . . . . . . . . . . . . . . . . . 64
Schlemm Canal. . . . . . . . . . . . . . . . . . . . . . . . . 64
Collector Channels . . . . . . . . . . . . . . . . . . . . . . . 64
Uvea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Iris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Stroma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Vessels and Nerves . . . . . . . . . . . . . . . . . . . . . . . 69
Dilator Muscle and Anterior Pigmented Epithelium . . . . . . . . . 70
Sphincter Muscle . . . . . . . . . . . . . . . . . . . . . . . . 71
Posterior Pigmented Epithelium. . . . . . . . . . . . . . . . . . 71
Ciliary Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Ciliary Epithelium and Stroma . . . . . . . . . . . . . . . . . . 72
Ciliary Muscle . . . . . . . . . . . . . . . . . . . . . . . . . 75
Supraciliary Space. . . . . . . . . . . . . . . . . . . . . . . . 76
Choroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Choriocapillaris and Choroidal Vessels. . . . . . . . . . . . . . . 76
Choroidal Stroma . . . . . . . . . . . . . . . . . . . . . . . . 77
Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Epithelium . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Fibers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Zonular Fibers . . . . . . . . . . . . . . . . . . . . . . . . . 82
Ret ina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Neurosensory Ret ina . . . . . . . . . . . . . . . . . . . . . . 84
Topography of the Ret ina . . . . . . . . . . . . . . . . . . . . 93
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Contents (cid:2) ix
Ret i nal Pigment Epithelium . . . . . . . . . . . . . . . . . . . . . 97
Bruch Membrane. . . . . . . . . . . . . . . . . . . . . . . . . . 99
Ora Serrata . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Vitreous. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
3 Cranial Nerves: Central and Peripheral
Connections . . . . . . . . . . . . . . . . . . . . . . . . . 105
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Olfactory Nerve (First Cranial Nerve) . . . . . . . . . . . . . . . . . 105
Optic Nerve (Second Cranial Nerve) . . . . . . . . . . . . . . . . . 109
Intraocular Region . . . . . . . . . . . . . . . . . . . . . . . 110
Intraorbital Region . . . . . . . . . . . . . . . . . . . . . . . 113
Intracanalicular Region . . . . . . . . . . . . . . . . . . . . . 115
Intracranial Region . . . . . . . . . . . . . . . . . . . . . . . 115
Visual Pathway . . . . . . . . . . . . . . . . . . . . . . . . . 115
Blood Supply of the Optic Nerve and Visual Pathway. . . . . . . . . 119
Oculomotor Nerve (Third Cranial Nerve) . . . . . . . . . . . . . . . 123
Pathways for the Pupil Ref lexes . . . . . . . . . . . . . . . . . . 126
Trochlear Nerve (Fourth Cranial Nerve) . . . . . . . . . . . . . . . . 127
Trigeminal Nerve (Fifth Cranial Nerve) . . . . . . . . . . . . . . . . 128
Mesencephalic Nucleus . . . . . . . . . . . . . . . . . . . . . 129
Main Sensory Nucleus . . . . . . . . . . . . . . . . . . . . . . 129
Spinal Nucleus and Tract. . . . . . . . . . . . . . . . . . . . . 130
Motor Nucleus . . . . . . . . . . . . . . . . . . . . . . . . . 131
Intracranial Pathway of Cranial Nerve V . . . . . . . . . . . . . . 131
Divisions of Cranial Nerve V . . . . . . . . . . . . . . . . . . . 131
Abducens Nerve (Sixth Cranial Nerve) . . . . . . . . . . . . . . . . 133
Facial Nerve (Seventh Cranial Nerve) . . . . . . . . . . . . . . . . . 133
Tear Ref lex Pathway . . . . . . . . . . . . . . . . . . . . . . . 135
The Ce re bral Vascular System . . . . . . . . . . . . . . . . . . . . 135
Cavernous Sinus . . . . . . . . . . . . . . . . . . . . . . . . 135
Other Venous Sinuses . . . . . . . . . . . . . . . . . . . . . . 136
Circle of Willis . . . . . . . . . . . . . . . . . . . . . . . . . 138
PART II Embryology 141
. . . . . . . . . . . . . . . . . . . . . .
4 Ocular Development . . . . . . . . . . . . . . . . . . . . 143
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
General Princi ples . . . . . . . . . . . . . . . . . . . . . . . . . 143
Eye Development. . . . . . . . . . . . . . . . . . . . . . . . . . 148
Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Posterior Segment. . . . . . . . . . . . . . . . . . . . . . . . 155
Uvea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Cornea, Anterior Chamber, and Sclera . . . . . . . . . . . . . . . 161
Development of the Extraocular Muscles, Adnexa, and Orbit . . . . . . . 162
Extraocular Muscles. . . . . . . . . . . . . . . . . . . . . . . 162
Adnexa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Orbit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
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