Ординатура / Офтальмология / Английские материалы / Comprehensive Ophthalmology_Khurana_2007

Enumerate the signs of aphakia.

Deep anterior chamber

Iridodonesis

Jet black pupil

Purkinje’s image test shows only two images (normally four)

Fundus examination shows small optic disc

Retinoscopy reveals high hypermetropia

What is pseudophakia?

Pseudophakia refers to presence of an intraocular lens in the pupillary area.

What is the refractive position of the pseudophakic

eye ?

A pseudophakic eye may be emmetropic, myopic or hypermetropic depending upon the power of the IOL implanted.

What is the average standard power of the

posterior chamber IOL ?

Exact power of an IOL to be implanted varies from individual to individual and is calculated by biometry using keratometer and A-scan ultrasound.

What is the average weight of an IOL?

Average weight of an IOL in air is 15 mg and in aqueous humour is about 5 mg.

What is the power of the IOL in air vis-a-vis in the

aqueous humour?

Power of an IOL in air is much more (about +60D) than that in the aqueous humour (about + 20D).

What is the difference in the power of an anterior

chamber IOL versus posterior chamber IOL ?

Equivalent power of an anterior chamber IOL is less (say about +18D) than that of posterior chamber IOL (+20D).

What is myopia (short-sightedness) ?

Myopia is a refractive error in which parallel rays of light coming from infinity are focused in front of the retina when accommodation is at rest.

Name the clinical varieties of myopia ?

1.Congenital myopia

2.Simple myopia

3.Pathological or degenerative myopia

4.Acquired myopia which may be: (i) post-traumatic,

(ii)post-keratitis, (iii) space myopia, and (iv) consecutive myopia (following overcorrection of aphakia by intraocular lens).

Enumerate the fundus changes in pathological myopia.

1.Optic disc appears large, pale and at its temporal edge characteristic myopic crescent is present.

2.Chorioretinal degeneration.

3.Foster-Fuchs’ spot at the macula.

4.Vitreous shows synchysis and syneresis.

5.Posterior staphyloma may be seen.

Name the surgical treatment of myopia.

1.Radial keratotomy

2.Photorefractive keratectomy (PRK) using excimer laser.

3.Automated microlamellar keratectomy (ALK)

4.Removal of clear crystalline lens by extracapsular cataract extraction (ECCE) is recommended in unilateral very high myopia.

Name the complications of pathological myopia.

Complicated cataract

Choroidal haemorrhage

Tears and haemorrhage in the retina

Vitreous haemorrhage

Retinal detachment

Name the diseases which can be associated with myopia.

Microphthalmos

Congenital glaucoma

Microcornea

Retrolental fibroplasia

Marfan’s syndrome

Turner’s syndrome

Ehlers-Danlos syndrome

What is the basic principle of radial keratotomy

operation for myopia ?

In radial keratotomy operation, multiple radial incisions are given in the periphery of cornea (leaving central 4 mm optical zone) in order to flatten the curvature of cornea.

What is the principle of photorefractive

keratectomy (PRK) operation for myopia?

In it, superficial keratectomy (reshaping) is performed in the central part of cornea with the help of excimer laser.

What is ALK operation for myopia?

It is automated lamellar keratectomy. In it a small disc of corneal stroma is removed with the help of an automated machine.

What is LASIK operation for myopia?

It is laser-assisted in-situ keratomileusis. It is performed using ALK machine and the excimer laser. This procedure is good for myopia of more than – 8D.

Define astigmatism.

Astigmatism is a type of refractive error, wherein the refraction varies in the different meridia. Consequently, the rays of light entering in the eye cannot converge to a point focus but form focal lines.

What are the clinical types of astigmatism?

1.Regular astigmatism, which may be:

(i)With-the-rule (WTR) astigmatism, wherein the vertical meridian is more curved than the horizontal.

(ii)Against-the-rule (ATR) astigmatism, wherein the horizontal meridian is more curved than the vertical meridian.

(iii)Oblique astigmatism, wherein the two principal meridia are not the horizontal and vertical though these are at right angles to one another (e.g., 45° and 135°).

(iv)Bioblique astigmatism, wherein the two principal meridia are not at right angle to each other, e.g., one may be at 30° and the other at 100°.

2.Irregular astigmatism: In it refraction varies in multiple meridia which admits no geometrical analysis. It commonly follows corneal scarring.

What is the treatment of irregular astigmatism?

Contact lens prescription, which replaces the anterior surface of the cornea for refraction.

What is simple, compound and mixed astigmatism?

1.Simple astigmatism. Herein the rays of light entering the eye are focused on the retina in one meridian and either in front (simple myopic astigmatism, or behind (simple hypermetropic astigmatism) the retina in other meridian.

2.Compound astigmatism. In this type of astigmatism, light rays are focused in both the principal meridia either in front (compound myopic astigmatism) or behind (compound hypermetropic astigmatism) the retina.

3.Mixed astigmatism. In this condition, light rays are focused in front of the retina in one meridian and behind the retina in the other meridian.

What is the most common cause of irregular

astigmatism?

Irregular corneal scars.

What is anisometropia?

In it, total refraction of the two eyes is unequal. Practically a difference of more that 2.5 D (which causes more than 5% difference in the retinal images of the two eyes) poses problem of anisometropia.

What is aniseikonia ?

Aniseikonia is defined as a condition, wherein the images projected to the visual cortex from the two retinae are abnormally unequal in size and shape.

How much image magnification is caused by one

dioptre anisometropia?

One dioptre anisometropia produces image magnification by 2 percent. An image difference up to 5 percent to 7 percent is well tolerated.

What are the common causes of aniseikonia?

Aniseikonia may be optical (due to high anisometropia), retinal (due to stretching or crowding of retina in macular area) or cortical (due to abnormal cortical perception of the images).

ACCOMMODATION AND ITS ANOMALIES

Define accommodation?

Accommodation is a mechanism by which the eyes can focus the diverging rays coming from a near object on the retina. In it, there occurs increase in the power of crystalline lens.

What is presbyopia ?

Presbyopia is not an error of refraction but a condition of physiological insufficiency of accommodation resulting from the decreased elasticity and plasticity of the lens due to advancing age (usually after the age of 40 years) leading to failing vision for near.

What is near point of the eye?

The nearest point at which small objects can be seen clearly is called near point or punctum proximum. Its value varies with age; being about 7 cm at 10 years of age and about 25 cm at about 40 years of age.

What is far point of the eye ?

The farthest point from where objects can be seen by the eye is called far point or punctum remotum. In an emmetropic eye, far point is at infinity.

Enumerate the causes of premature resbyopia?

1.Uncorrected hypermetropia

2.Premature hardening of the lens

3.General debility causing premature senile weakness of the ciliary muscle

4.Chronic simple glaucoma

What is range of accommodation ?

Range of accommodation is the distance between the near point and far point of the eye.

What is amplitude of accommodation?

Amplitude of accommodation is the difference between the dioptric power needed to focus at near point and far point.

What do you mean by insufficiency of accommo-

dation? Enumerate its causes.

Insufficiency of accommodation refers to a significant decrease in accommodation power than the normal physiological limit for the patient’s age. Common causes of insufficiency of accommodation are:

Premature sclerosis of the lens.

Weakness of ciliary muscle associated with chronic debilitating disease, anaemia, malnutrition, pregnancy, stress and so on.

Primary open-angle glaucoma.

DETERMINATION AND CORRECTION OF REFRACTIVE ERRORS

Enumerate objective methods of refraction.

Retinoscopy

Autorefractometry

Keratometry

Name some subjective methods of refraction.

Trial and error method

Fogging method

Tests for confirming refraction subjectively

–Duochrome test

–Astigmatic fan test

–Jackson’s crosscylinder test

–Pin-hole test

Define retinoscopy (skiascopy or shadow test).

Retinoscopy is an objective method of finding out the error of refraction by the method of neutralization.

What is the principle of retinoscopy?

Retinoscopy is based on the fact that when light is reflected from a mirror into the eye, the direction in which light will travel across the pupil will depend upon the refractive state of the eye.

What are the prerequisites for retinoscopy?

1.A darkroom preferably 6-m long or which can be converted into 6 metres by the use of a plane mirror.

2.A trial box containing spherical and cylindrical lenses of variable plus and minus powers, a pinhole, an occluder and prisms.

3.A trial frame

4.A Snellen’s self-illuminated vision box

5.A retinoscope

What are the common types of retinoscopes?

1.Mirror retinoscopes, which may consist of a simple plane mirror or a combination of a plane mirror (on one end) and a concave mirror (on the other end). e.g., Pristley-Smith’s mirror.

2.Self-illuminated streak retinoscope.

What are the advantages of a streak retinoscope

over a simple plane mirror retinoscope ?

The streak retinoscope is more sensitive than the spot retinoscope in detecting astigmatism.

Name the conditions where concave mirror retinoscopy is more useful.

1.Patient with hazy media.

2.Patient with very high degree of refractive error.

What are the indications of using cycloplegic drugs

for retinoscopy?

Cycloplegics are used before retinoscopy in patients where the examiner suspects that accommodation is abnormally active and will hinder the exact retinoscopy. Such a situation is encountered in young children especially hypermetropes.

What do you mean by wet retinoscopy and dry

retinoscopy?

When retinoscopy is performed after instilling a cycloplegic, it is termed ‘wet-retinoscopy’ in converse to dry retinoscopy (without cycloplegic).

Name the commonly used cycloplegics.

1.Atropine

2.Homatropine

3.Cyclopentolate

At what distance retinoscopy is performed?

One meter or two-third metre.

When retinoscopy is performed with a plane mirror at a distance of 1 m; what inferences are

drawn?

Depending upon the movement of the red reflex vis- a-vis movement of the plane mirror, following inferences are drawn:

1.No movement of the red reflex indicates myopia of 1 D.

2.With movement of the red reflex indicates either emmetropia or hypermetropia or myopia of less than 1 D.

3.Against movement indicates myopia of more than 1D.

What inferences are drawn from the movement of the red reflex when concave mirror retinoscope

is used?

The inferences drawn while using a concave mirror are reverse to that of plane mirror.

What is the point of neutralization while using a

simple plane mirror retinoscope?

The end point of neutralization is either no movement or just reversal of the movement of the pupillary shadow.

What is the end point of neutralization while using

a streak retinoscope?

At the end point, the streak disappears and the pupil appears completely illuminated or completely dark.

While performing retinoscopy, if the shadow

appears to swirl around, what does it indicate?

Astigmatism.

While performing retinoscopy with dilated pupil, one central and another peripheral shadow may be seen. It is important to neutralize which

shadow?

Central shadow.

When a cycloplegic retinoscopy has been performed, how many dioptres should be deducted to compensate for the ciliary tone?

1 D for atropine

0.75 D for cyclopentolate

0.5 D for homatropine

What is an autorefractometer?

It is a computerized refractometer which quickly estimates the refractive error of the patient objectively in terms of sphere, cylinder with its axis and interpupillary distance. The subjective verification is a must even after autorefractometry.

What is a duochrome test ?

Duochrome test is based on the principle of chromatic aberrations. It helps in verifying the spherical correction subjectively. In it, the patient is asked to tell the clarity of the letters with red background vis- a-vis green background. To an emmetropic patient,

letters of both the colours look equally sharp; while to a slightly myopic patient the red letters appear sharper and to a slightly hypermetropic patient the green letters look sharper.

Name common problems which can arise while

performing retinoscopy.

Red reflex may not be visible. It occurs in:

small pupil,

hazy media, and

high degree of refractive errors.

DARKROOM APPLIANCES

What is a prism and what are its uses in

ophthalmology?

Prism is a refracting medium, having two plane surfaces inclined at an angle. Its uses are:

1.Objective measurement of angle of squint (prism bar cover test, Krimsky’s test).

2.Measurement of fusional reserve.

3.Diagnosis of microtropia.

4.Used in ophthalmic equipment such as gonioscope, keratometer, applanation tonometer, etc.

What are the uses of a convex spherical lens?

Its uses are:

For correction of hypermetropia, aphakia and presbyopia

In oblique illumination examination

In indirect ophthalmoscopy

As a magnifying lens

How will you identify a convex lens ?

A convex lens can be identified from following features:

It is thicker at the centre.

An object held close to it appears magnified.

When it is moved, the objects seen through it move in the opposite direction.

How will you identify a concave lens

A concave lens can be identified from following features:

It is thin at the centre and thick at the periphery.

An object seen through it appears minified.

When it is moved, the objects seen through it move in the same direction of the lens.

What are the uses of concave lens?

For correction of myopia

As Hruby lens for fundus examination.

How will you identify a cylindrical lens?

When it is rotated around its optical axis, objects seen through it become distorted.

It acts only in one axis, i.e., when it is moved up and down or sideways the object seen through it moves only in one direction (with the lens in a convex cylinder and against the lens in a concave cylinder).

What are the uses of cylindrical lenses ?

Cylindrical lens is prescribed to: (i) correct astigmatic refractive error, (ii) it is used as a crosscylinder to check the power and axis of the cylindrical lens prescribed, subjectively.

What is a crosscylinder and what are its uses?

The Jackson’s crosscylinder is a combination of two cylindrical lenses of equal strength but with opposite sign placed with their axis at right angles to each other and mounted in a handle. The crosscylinder effect is obtained by combining a spherical lens with a cylindrical lens (double the power of spherical lens) with opposite sign –0.25 D spherical and +0.5 D cylindrical. Commonly used crosscylinders are a combination of 0.25 D and 0.5 D.

A crosscylinder is used to verify the strength and axis of the cylinder subjectively.

What are the uses of red and green glasses or

filters?

These are used for:

Diplopia charting

Worth’s four-dot test

Malingering test

While testing, the red glass is kept in front of the right eye and the green glass is kept in front of the left eye.

Which glass is used most commonly for making

spectacles?

Crown glass with refractive index 1.5223 is most commonly used for making spectacles.

What are the types of contact lenses you know of?

Hard contact lenses

Soft contact lenses

Rigid gas-permeable (RGP) contact lenses

What are the advantages and disadvantages of

hard contact lenses?

Hard contact lenses are made up of PMMA (polymethylmethacrylate) which is a light weight, nontoxic but of hydrophobic material.

Advantages

Cheap, durable and have high optical quality.

Disadvantages

Can cause corneal hypoxia and corneal abrasions.

What are the advantages and disadvantages of

soft contact lenses?

Soft contact lenses are made up of HEMA (hydroxyethylmethacrylate) which is hydrophilic.

Advantages

Being soft and oxygen permeable, they are most comfortable and so well tolerated.

Disadvantages

Problems of proteinaceous deposits, getting cracked, limited life, inferior optical quality, more chances of corneal infections, and inability to correct astigmatism of more than one dioptre.

OPHTHALMOSCOPY

TECHNIQUES OF FUNDUS EXAMINATION

A.Ophthalmoscopy, and

B.Slit-lamp biomicroscopic examination of the fundus by:

Indirect slit-lamp biomiscroscopy

Hruby lens biomicroscopy

Contact lens biomicroscopy

A. OPHTHALMOSCOPY

Ophthalmoscopy is a clinical examination of the interior of the eye by means of an ophthalmoscope. It is primarily done to assess the state of fundus and detect the opacities of ocular media. The ophthalmoscope was invented by Babbage in 1848, however its importance was not recognized, and it was re-invented by von Helmholtz in 1850. Three methods of examination in vogue are: (1) distant direct ophthalmoscopy, (2) direct ophthalmoscopy, and (3) indirect ophthalmoscopy.

1. DISTANT DIRECT OPHTHALMOSCOPY

It should be performed routinely before the direct ophthalmoscopy, as it gives a lot of useful information (vide infra). It can be performed with the help of a self-illuminated ophthalmoscope or a simple plain mirror with a hole at the centre.

Procedure. The light is thrown into patient’s eye sitting in a semi-darkroom, from a distance of 20-25 cm and the features of the red glow in the pupillary area are noted.

Applications of distant direct ophthalmoscopy

i.To diagnose opacities in the refractive media.

Any opacity in the refractive media is seen as a black shadow in the red glow. The exact location of the opacity can be determined by observing the parallactic displacement. For this, the patient is asked to move the eye up and down while the examiner is observing the pupillary glow. The opacities in the pupillary plane remain stationary, those in front of the pupillary plane move in the direction of the movement of the eye and those behind it will move in opposite direction (Fig. 23.25).

ii.To differentiate between a mole and a hole of the iris. A small hole and a mole on the iris appear as a black spot on oblique illumination. On distant direct ophthalmoscopy, the mole looks black (as earlier) but a red reflex is seen through the hole in the iris.

iii.To recognize detached retina or a tumour arising from the fundus. A grayish reflex seen on distant direct ophthalmoscopy indicates either a detached retina or a tumour arising from the fundus.

2. DIRECT OPHTHALMOSCOPY

It is the most commonly practised method for routine fundus examination.

Optics. The modern direct ophthalmoscope (Fig. 23.26) works on the basic optical principle of glass plate ophthalmoscope introduced by von Helmholtz. Optics of direct ophthalmoscopy is depicted in Figure 23.27.

A convergent beam of light is reflected into the patient’s pupil (Fig. 23.27, dotted lines). The emergent rays from any point on the patient’s fundus reach the observer’s retina through the viewing hole in the ophthalmoscope (Fig. 23.27, continuous lines). The emergent rays from the patient’s eye are parallel and brought to focus on the retina of the emmetropic observer when accommodation is relaxed. However, if the patient or/and the observer is/are ametropic, a correcting lens (equivalent to the sum of the patient’s and observer’s refractive error) must be interposed (from the system of plus and minus lenses, inbuilt in the modern ophthalmoscopes).

Characteristics of image formed. In direct ophthalmoscopy, the image is erect, virtual and about 15 times magnified in emmetropes (more in myopes and less in hypermetropes).

Technique. Direct ophthalmoscopy should be performed in a semi-darkroom with the patient seated and looking straight ahead, while the observer standing or seated slightly over to the side of the eye to be examined (Fig. 23.28). Patients right eye should be examined by the observer with his or her right eye and left with the left.

The observer should reflect beam of light from the ophthalmoscope into patient’s pupil. Once the red reflex is seen the observer should move as close to the patient’s eye as possible (theoretically at the anterior focal plane of the patient’s eye, i.e., 15.4 mm from the cornea). Once the retina is focused the details should be examined systematically starting from disc, blood vessels, the four quadrants of the general background and the macula.

3. INDIRECT OPHTHALMOSCOPY

Indirect ophthalmoscopy introduced by Nagel in 1864, is now a very popular method for examination of the posterior segment.

Optical principle. The principle of indirect ophthalmoscopy is to make the eye highly myopic by placing a strong convex lens in front of patient’s eye so that the emergent rays from an area of the fundus are brought to focus as a real, inverted image between the lens and the observer’s eye, which is then studied (Fig. 23.29).

Characteristics of image. The image formed in indirect ophthalmoscopy is real, inverted and magnified. Magnification of image depends upon the dioptric power of the convex lens, position of the lens in relation to the eyeball and refractive state of

Fig. 23.28. Technique of direct ophthalmoscopy.

the eyeball. About 5 times magnification is obtained with a +13 D lens. With a stronger lens, image will be smaller, but brighter and field of vision will be more.

Prerequisites. (i) Darkroom, (ii) source of light and concave mirror or self-illuminated indirect ophthalmoscope, (iii) convex lens (now-a-days commonly employed lens is of +20 D), (iv) pupils of the patient should be dilated.

Technique. The patient is made to lie in the supine position, with one pillow on a bed or couch and instructed to keep both eyes open. The examiner throws the light into patient’s eye from an arm’s distance (with the self-illuminated ophthalmoscope). In practice, binocular ophthalmoscope with head band or that mounted on the spectacle frame is employed most frequently (Fig. 23.30). Keeping his or her eyes on the reflex, the examiner then interposes the condensing lens (+20 D, routinely) in the path of beam of light, close to patient’s eye, and then slowly moves the lens away from the eye (towards himself) until the image of the retina is clearly seen. The examiner moves around the head of the patient to examine different quadrants of the fundus. He or she has to stand opposite the clock hour position to be examined, e.g., to examine inferior quadrant (around 6 O’clock meridian) the examiner stands towards patient’s head (12 O’clock meridian) and so on. By asking the patient to look in extreme gaze, and using of scleral indenter, the whole peripheral retina up to ora serrata can be examined.

Applications. Indirect ophthalmoscopy is essential for the assessment and management of retinal detachment and other peripheral retinal lesions.

Difficulties

1.The technique is difficult and can be mastered by hours of practice.

2.Reflexes from the corneal surface can be decreased by holding the condensing lens at a distance equal to its focal length from the anterior focus of the eye.

Fig. 23.30. Technique of indirect ophthalmoscopy.

3.Formation of reflexes by the two surfaces of convex lens can be eliminated by slightly tilting

the lens and use of aspheric lens.

Advantages of the binocular indirect ophthalmoscope

1.The inbuilt illumination is strong and its intensity can be changed.

2.It allows stereoscopic view of the image.

Direct versus indirect ophthalmoscopy. See Table 23.2.

B. SLIT-LAMP BIOMICROSCOPIC EXAMINATION OF THE FUNDUS

Biomicroscopic examination of the fundus can be performed after full mydriasis using a slit-lamp and any one of the following lenses:

1.Indirect slit-lamp biomicroscopy. +78 D, +90 D small diameter lenses (Fig. 23.31A) is presently the most commonly employed technique for biomicroscopic examination of the fundus.

2.Hruby lens biomicroscopy. Hruby lens is a planoconcave lens with dioptric power 58.6D (Fig. 23.31B). This lens provides a small field with low magnification and cannot visualize the fundus beyond equator.

3.Contant lens biomicroscopy can be performed by following lenses:

Posterior fundus contact lens is a modified

Koeppe’s lens (Fig. 23.31C). The image produced by it is virtual and erect.

Goldmann’s three-mirror contact lens consists of a central contact lens and three mirrors placed in the cone, each with different angles of inclination (Fig. 23.31D). With this the central as well as peripheral parts of the fundus can be visualized.

RELATED QUESTIONS

Fig. 23.31. Lenses used for slit-lamp biomicroscopic examination of fundus: A, +78D or +90D, small diameter lens. B, Hruby lens; C, Posterior fundus contact lens (modified Koeppe’s lens); D, Goldmann’s three-mirror contact lens.

What are the types of ophthalmoscopy?

Ophthalmoscopy is of three types:

1.Distant direct ophthalmoscopy.

2.Direct ophthalmoscopy

3.Indirect ophthalmoscopy

What are the other methods of fundus examination?

Define ophthalmoscopy.

It is a darkroom procedure carried out to examine the fundus oculi.

In addition to ophthalmoscopy fundus can also be examined by focal illumination using a slit-lamp biomicroscope and any of the following lenses:

Hruby lens

Posterior fundus contact lens

Goldmann’s three-mirror contact lens

+78 D and +90 D small diameter lenses.

When and who invented the direct

ophthalmoscope?

Babbage in 1848.

Who reinvented and popularised the ophthal-

moscope?

von Helmholtz in 1850.

At what distance distant direct ophthalmoscopy

is performed?

20-25 cm.

What are the uses (applications) of distant direct ophthalmoscopy?

1.To diagnose opacities in the ocular media

2.To differentiate between a mole and a hole of the iris.

3.To recognize a detached retina

4.To recognize a subluxated lens.

At what distance ‘direct ophthalmoscopy’ should

be performed?

As near to the patient’s eye as possible.

What are the features of the image formed in direct

ophthalmoscopy?

The image formed is erect, virtual and about 15 times magnified in an emmetrope.

When and who invented the indirect ophthalmo-

scopy?

Nagel in 1864

What is the principle of indirect phthalmoscopy?

The principle of indirect ophthalmoscopy is to make the eye highly myopic by placing a strong convex lens in front of the patient’s eye so that emergent rays from an area of the fundus are brought to focus as a real, inverted image between the lens and the observer’s eye.

What are the characteristics of the image formed in indirect ophthalmoscopy?

It is real, inverted, magnified about 5 times when +13 D lens is used and is formed between the convex lens and the observer.

What is the power of the convex lens most commonly used in indirect ophthalmoscopy?

+20D.

What are the advantages of indirect ophthalmoscopy over direct ophthalmoscopy?

1.It allows a stereoscopic view of the fundus.

2.It allows examination in hazy media.

3.Periphery of the retina up to ora serrata can be examined.

What are the advantages of direct ophthalmoscopy over indirect ophthalmoscopy?

1.It is a handy procedure

2.Easy to perform

3.Allows examination of the minute details of the approachable lesion, since image formed is 15 times magnified.

4.Orientation and understanding of the lesion is easy as the image formed is erect.

Name the common diseases of the optic disc which can be diagnosed on direct ophthalmoscopy.

Papillitis

Papilloedema

Optic atrophy

Glaucomatous cupping

Name few common retinal disorders diagnosed on direct/ indirect ophthalmoscopy.

Diabetic retinopathy

Hypertensive retinopathy

Retinal detachment

Retinitis pigmentosa