examination of eye pt ii
Post on 30-Nov-2015
72 Views
Preview:
DESCRIPTION
TRANSCRIPT
Examination of EyeExamination of EyeExamination of Anterior SegmentExamination of Anterior Segment
Part - IIPart - II
Examination of Cornea Examination of Cornea
Examination of cornea is done under Examination of cornea is done under the following headingsthe following headings
1.1. ShapeShape
2.2. SizeSize
3.3. SurfaceSurface
4.4. TransparencyTransparency
5.5. Corneal SensationCorneal Sensation
Uniocular Loupe Uniocular Loupe
Examination of CorneaExamination of Cornea
Size Size
Normal DiameterNormal Diameter
HorizontalHorizontal 11 mm11 mm
VerticalVertical 10.6 mm10.6 mm
Size Measured by Size Measured by
Transparent ruleTransparent rule
Slit LampSlit Lamp
Corneal SizeCorneal Size
Size Increased Size Increased
- Megalocornea- Megalocornea
- Buphthalmos- Buphthalmos
- Keratoglobus- Keratoglobus
Size Decreased :Size Decreased :
- Microcornea- Microcornea
- Microphthalmos- Microphthalmos
Corneal ShapeCorneal Shape
Shape of Cornea Shape of Cornea
Normal cornea is elliptical with Normal cornea is elliptical with regular curvature.regular curvature.
Examined by help of slit beam on slit Examined by help of slit beam on slit lamp.lamp.
CurvatureCurvature
Flat Cornea :Flat Cornea :Cornea plateauCornea plateauAtrophic bulbiAtrophic bulbi
Conical Cornea :Conical Cornea :KeratoconusKeratoconus
Globular Cornea :Globular Cornea :KeratoglobusKeratoglobusAnterior staphylomaAnterior staphylomaBuphthalmosBuphthalmos
Corneal Surface Corneal Surface
Surface :Surface :
Corneal surface is normally smooth Corneal surface is normally smooth regularregular
Examined with the help of placido Examined with the help of placido disk reflex, window reflex, corneal disk reflex, window reflex, corneal staining or sophisticated corneal staining or sophisticated corneal topography machine.topography machine.
Corneal SurfaceCorneal Surface
Placido Disk :Placido Disk :
Hold the disk in front of the patient Hold the disk in front of the patient cornea and look through the lens in cornea and look through the lens in centre of disk at patient’s cornea.centre of disk at patient’s cornea.
The image of disc (circles) is seen on The image of disc (circles) is seen on patient cornea if they are regular patient cornea if they are regular surface is smooth and regular. surface is smooth and regular.
Corneal Transparency Corneal Transparency
Transparency of Cornea :Transparency of Cornea :Normal cornea is uniformly transparent Normal cornea is uniformly transparent Hazy in :Hazy in :
Corneal edema due to –Corneal edema due to –KeratitsKeratitsBullous Keratopathy.Bullous Keratopathy.Glaucoma (Acute Congestive)Glaucoma (Acute Congestive)IridocyctitisIridocyctitisAcute hydropsAcute hydropsCorneal dystrophy.Corneal dystrophy.
Corneal edema in Angle Closure Corneal edema in Angle Closure GlaucomaGlaucoma
Corneal UlcerCorneal Ulcer
Corneal Opacity Corneal Opacity
Corneal Opacity :Corneal Opacity :Opacity should be examine under Opacity should be examine under following head –following head –1.1. Number of opacityNumber of opacity2.2. Size and shapeSize and shape3.3. SiteSite4.4. TypeType5.5. Vascularization Vascularization
Corneal Opacity Corneal Opacity
Type of Corneal Opacity :Type of Corneal Opacity :
Nebular – Iris details clearly visible at Nebular – Iris details clearly visible at level of anterior stroma and Bowman level of anterior stroma and Bowman membrane.membrane.
Macular – Iris details visible, ½ of stroma.Macular – Iris details visible, ½ of stroma.
Leucomatous – No iris details are visible.Leucomatous – No iris details are visible.
The whole stroma is involvedThe whole stroma is involved
Nebulomacular Corneal OpacityNebulomacular Corneal Opacity
Leucomatous Corneal OpacityLeucomatous Corneal Opacity
Leucomatous Corneal OpacityLeucomatous Corneal Opacity
Corneal EdemaCorneal Edema
Corneal OpacityCorneal Opacity
Leucomatous corneal opacity may be Leucomatous corneal opacity may be seen in association with seen in association with
Anterior SynechiaAnterior Synechia
Adherent LeucomaAdherent Leucoma
Corneoiridic scarCorneoiridic scar
Opacity also looked for any abnormal Opacity also looked for any abnormal pigmentation and degeneration.pigmentation and degeneration.
Salzman Nodular DegenerationSalzman Nodular Degeneration
Vascularization of Cornea Vascularization of Cornea Superficial Superficial 1. Vessel can be traced 1. Vessel can be traced
over limbus into over limbus into conjunctivaconjunctiva
2. Sup. vessels are bright 2. Sup. vessels are bright red & well defined red & well defined
3. Sup. vessels branch 3. Sup. vessels branch dichotomously in an dichotomously in an arborescent fashion arborescent fashion
4. 4. Sup. vessels raise the Sup. vessels raise the
epithelium over them so epithelium over them so corneal surface is uneven corneal surface is uneven
Deep Deep 1. Deep vessel end abruptly 1. Deep vessel end abruptly
at the limbus at the limbus
2. Ill defined purplish red or 2. Ill defined purplish red or red bluish red bluish
3. Deep vessels run parallel. 3. Deep vessels run parallel. Branch acute angle and Branch acute angle and their course is their course is determined by lamellar determined by lamellar structure of cornea. structure of cornea.
4. Cornea is smooth and 4. Cornea is smooth and hazy. hazy.
Superficial VascularizationSuperficial Vascularization
Corneal SensationCorneal Sensation
Method :Method : Patient is asked to see forward.Patient is asked to see forward.A whisp of cotton is touched to cornea on A whisp of cotton is touched to cornea on temporal side, nasal, superior, inferior and temporal side, nasal, superior, inferior and central regions and observe for blinking of central regions and observe for blinking of eye.eye.
Decreased Corneal Sensation, seen in :Decreased Corneal Sensation, seen in :-- Herpes simplex,Herpes simplex, - Lesion of 5- Lesion of 5thth nerve nerve-- Herpes zosterHerpes zoster - Keratomalacia - Keratomalacia-- Absolute glaucoma - LeprosyAbsolute glaucoma - Leprosy
Keratic Precipitation (K.P.)Keratic Precipitation (K.P.)
These are deposits of inflammatory These are deposits of inflammatory cells on the endothelium of cornea.cells on the endothelium of cornea.
-- Fine K.P.Fine K.P.
-- Mutton fat K.P.Mutton fat K.P.
-- Pigmented K.P. (old)Pigmented K.P. (old)
Cause – Iridocyclitis Cause – Iridocyclitis
Ciliary Congestion + KPs in a case Ciliary Congestion + KPs in a case of Iridocyclitisof Iridocyclitis
Slit lampSlit lamp
Slit Lamp ExaminationSlit Lamp Examination
Technique of examination of Technique of examination of cornea on slit lampcornea on slit lamp1.1. Diffuse illumination Diffuse illumination
2.2. Direct focal illumination Direct focal illumination
3.3. Indirect illumination Indirect illumination
4.4. Retroillumination Retroillumination
5.5. Sclerotic Scatter Sclerotic Scatter
6.6. Specular Microscopy Specular Microscopy
ScleraSclera
Is white tough outer coat of eye with Is white tough outer coat of eye with protective function. This structure is protective function. This structure is avascular, dense fibrous tissue avascular, dense fibrous tissue covered anteriorly by conjunctivacovered anteriorly by conjunctiva
Sclera is examined by asking the Sclera is examined by asking the patient to up, down, medially and patient to up, down, medially and laterally by holding the lids to have laterally by holding the lids to have maximum viewmaximum view
Blue scleraBlue sclera
Abnormalities of ScleraAbnormalities of Sclera
1.1. Nodule Nodule
2.2. Thinning / pigmentationThinning / pigmentation
3.3. Ectasia Ectasia
EpiscleritisEpiscleritis
Examination of Ant. Chamber Examination of Ant. Chamber
Depth of A.C.Depth of A.C. Contents of A.C.Contents of A.C.
Normal depth of anterior chamber is Normal depth of anterior chamber is 2.5 mm2.5 mmDepth –Depth –Examine by slit beam on slit tamp or Examine by slit beam on slit tamp or by oblique torch light (rough idea)by oblique torch light (rough idea)
Anterior chamber may be normal, Anterior chamber may be normal, shallow or deep in depth shallow or deep in depth
Shallow ACShallow AC
Causes of shallow depth of anterior chamber Causes of shallow depth of anterior chamber Hypermetropic eyeHypermetropic eye MicrocorneaMicrocornea Flat corneaFlat cornea Narrow angle glaucomaNarrow angle glaucoma Intumescent cataractIntumescent cataract Traumatic cataractTraumatic cataract Ant. dislocation of lensAnt. dislocation of lens Choroidal detachmentChoroidal detachment Over filtering blebOver filtering bleb Malignant glaucomaMalignant glaucoma
Deep Anterior ChamberDeep Anterior Chamber
Causes of Deep Anterior Chamber Causes of Deep Anterior Chamber InfantsInfants High MyopiaHigh Myopia KeratoglobusKeratoglobus KeratoconusKeratoconus Buphthalmos.Buphthalmos. AphakiaAphakia Post dislocation of lensPost dislocation of lens Total post synechia Total post synechia
Irregular depth of Anterior Chamber Irregular depth of Anterior Chamber
CausesCauses Subluxation of lensSubluxation of lens Iris bombeIris bombe Adherent leucomaAdherent leucoma Traumatic cataractTraumatic cataract Tumor of iris and cilliary body.Tumor of iris and cilliary body.
Abnormal Contents of ACAbnormal Contents of AC
Cells (in uveitis ) – inflammatory cell in ACCells (in uveitis ) – inflammatory cell in AC Examined by conical beam of slit lampExamined by conical beam of slit lamp Aqueous flare – Protein in ACAqueous flare – Protein in AC Hypopyon – Pus in anterior chamberHypopyon – Pus in anterior chamber Hypopyon may be mobile or solid fixed Hypopyon may be mobile or solid fixed Hyphema – blood in A.C.Hyphema – blood in A.C. Cortical lens matterCortical lens matter Anterior chamber IOLAnterior chamber IOL Foreign bodyForeign body
HypaemaHypaema
HypopyonHypopyon
Angle of Anterior Chamber Angle of Anterior Chamber
Angle of anterior chamber is examined with Angle of anterior chamber is examined with Gonioscope (procedure is called Gonioscopy)Gonioscope (procedure is called Gonioscopy)
Structures forming angle of anterior Structures forming angle of anterior chamber are:chamber are:
1.1. Root of IrisRoot of Iris
2.2. Ciliary body bandCiliary body band
3.3. Scleral spurScleral spur
4.4. Trabecular MeshworkTrabecular Meshwork
5.5. Schwalbe lineSchwalbe line
Anatomy of Angle of ACAnatomy of Angle of AC
Sketch by Dr Shikha
GONIOSCOPIC VIEW GONIOSCOPIC VIEW
Sketch by Dr Shikha
Examination of Iris Examination of Iris
Points examined in Iris are Points examined in Iris are
1.1. Colour of Iris Colour of Iris 2.2. Pattern of irisPattern of iris3.3. Any adhesions of Iris Any adhesions of Iris 4.4. Persistant pupillary membrane Persistant pupillary membrane 5.5. IridodonesisIridodonesis6.6. Rubeosis IridisRubeosis Iridis7.7. Coloboma of Iris Coloboma of Iris 8.8. IridodialysisIridodialysis9.9. Aniridia Aniridia
Colour of Iris Colour of Iris
Colour: varies in different races. Normally Colour: varies in different races. Normally dark brown in Orientals. Light blue or dark brown in Orientals. Light blue or green in Caucasians.green in Caucasians.
Other variations in colour:Other variations in colour: Congenital heterochromia iridum- Congenital heterochromia iridum-
difference in colour of the two irises.difference in colour of the two irises. Heterochromia iridis- difference in colour Heterochromia iridis- difference in colour
of sectors of the same iris.of sectors of the same iris. Greyish atrophic patches in healed Greyish atrophic patches in healed
iridocyclitisiridocyclitis Darkly pigmented spots (naevi)Darkly pigmented spots (naevi)
Normal Pattern of IrisNormal Pattern of Iris
Note Iris Colour & PatternNote Iris Colour & Pattern
Healed IridocyclitisHealed Iridocyclitis
Post Laser IridotomyPost Laser Iridotomy
Pattern of Iris Pattern of Iris Pattern: Normal pattern consists of a collarets Pattern: Normal pattern consists of a collarets
dividing iris into papillary & ciliary zone, and dividing iris into papillary & ciliary zone, and ridges and crypts.ridges and crypts.
Muddy Iris- disturbance of normal pattern in acute Muddy Iris- disturbance of normal pattern in acute iridocyclitis.iridocyclitis.
Atrophic patches- in healed iridocyclitisAtrophic patches- in healed iridocyclitis Sectoral patches of atrophy- acute angle closure Sectoral patches of atrophy- acute angle closure
glaucoma, herpes zoster iritis.glaucoma, herpes zoster iritis. Brushfield spots- Downs syndromeBrushfield spots- Downs syndrome Pedunculated nodules- Lisch nodules in Pedunculated nodules- Lisch nodules in
neurofibromatosisneurofibromatosis Flat nodules at papillary margin- Koeppe nodulesFlat nodules at papillary margin- Koeppe nodules Flat nodules at peripheral base of iris- Busacca Flat nodules at peripheral base of iris- Busacca
nodulesnodules
Synechiae Synechiae
Persistent pupillary membrane- abnormal Persistent pupillary membrane- abnormal congenital tags of iris tissue adherent to congenital tags of iris tissue adherent to collarette.collarette.
Synechiae- adhesion of iris to other Synechiae- adhesion of iris to other intraocular structuresintraocular structures
Anterior synechiae- to posterior Anterior synechiae- to posterior surface of surface of corneacornea
Posterior synechiae- to anterior Posterior synechiae- to anterior surface of surface of lens. They may be-lens. They may be-
Segmental, total or annular.Segmental, total or annular.
IridocyclitisIridocyclitis
Posterior SynechiaPosterior Synechia
Other Abnormalities Other Abnormalities
Iridodonesis- tremulousness of iris due to Iridodonesis- tremulousness of iris due to loss of posterior support of lens in loss of posterior support of lens in aphakia or subluxation of lens.aphakia or subluxation of lens.
Rubeosis iridis- new vessels on surface of Rubeosis iridis- new vessels on surface of iris in diabetes mellitus, central retinal iris in diabetes mellitus, central retinal vein occlusion, chronic iridocyclitis.vein occlusion, chronic iridocyclitis.
Coloboma- gap or hole in irisColoboma- gap or hole in iris Iridodialysis- separation of iris from Iridodialysis- separation of iris from
ciliary body. ciliary body. Aniridia- complete absence of irisAniridia- complete absence of iris
IridodialysisIridodialysis
Coloboma of IrisColoboma of Iris
Examination of PupilExamination of Pupil
Pupils Pupils
Pupil is the circular aperture in the Pupil is the circular aperture in the centre of iris. Its normal size is 3-centre of iris. Its normal size is 3-4mm. it is grayish black in colour.4mm. it is grayish black in colour.
Points to be noted in pupilPoints to be noted in pupil
1. Number-normally there is one pupil. 1. Number-normally there is one pupil. More than one pupil is called More than one pupil is called polycoria.polycoria.
2. Location- normally almost central, 2. Location- normally almost central, slightly nasal. Eccentric pupil is slightly nasal. Eccentric pupil is called correctopia.called correctopia.
3. Size of pupils 3. Size of pupils
Pupillary size Pupillary size Size- 3-4 mm normal, depending on illuminationSize- 3-4 mm normal, depending on illumination Causes of abnormally small pupil - miosisCauses of abnormally small pupil - miosis
Local miotic Drugs (parasympathomimetic)Local miotic Drugs (parasympathomimetic)Systemic morphineSystemic morphineIridocyclitis- narrow, irregular, non-reacting pupilIridocyclitis- narrow, irregular, non-reacting pupilMorphineMorphineHorner’s syndromeHorner’s syndromeHead injury (pontine hemorrhage)Head injury (pontine hemorrhage)Senile miotic pupilSenile miotic pupilEffect of strong lightEffect of strong lightDuring sleepDuring sleep
Dilated pupilDilated pupil Causes of abnormally dilated pupil - mydriasisCauses of abnormally dilated pupil - mydriasis
Sympathomimetic drugs- adrenaline, Sympathomimetic drugs- adrenaline, phenilephrinephenilephrineParasympatholytic drugs- atropine, homatropine, Parasympatholytic drugs- atropine, homatropine, cyclopentolate, tropicamidecyclopentolate, tropicamideAcute congestive glaucoma (vertically oval, Acute congestive glaucoma (vertically oval, immobile pupil)immobile pupil)Absolute glaucomaAbsolute glaucomaOptic atrophy Optic atrophy Retinal detachmentRetinal detachmentInternal ophthalmoplegiaInternal ophthalmoplegia3rd nerve paralysis3rd nerve paralysisBelladonna poisoningBelladonna poisoning
Note Dilated pupil of Left eyeNote Dilated pupil of Left eye
Shape of pupil Shape of pupil
Shape normally circularShape normally circular Irregular narrow pupil- iridocyclitisIrregular narrow pupil- iridocyclitis Festooned pupil- irregular pupil Festooned pupil- irregular pupil
after patchy dilatation (effect of after patchy dilatation (effect of mydriatics in presence of posterior mydriatics in presence of posterior synechiae)synechiae)
Pupillary reactions Pupillary reactions
Pupillary ReflexesPupillary Reflexes Light reflex- Direct- throw light into Light reflex- Direct- throw light into
the eye, look for pupillary the eye, look for pupillary constriction in the same eyeconstriction in the same eye
Consensual - keep an obstruction Consensual - keep an obstruction between the two eyes. Throw light between the two eyes. Throw light in one eye, look for constriction in in one eye, look for constriction in other eye.other eye.
Yellow reflex in pupillary areaYellow reflex in pupillary area
Irregular pupil in a case of iridocyclitisIrregular pupil in a case of iridocyclitis
Pupillary reactionsPupillary reactions Swinging flash light test - patient is made to sit in Swinging flash light test - patient is made to sit in
a room with diffuse background illuminationa room with diffuse background illuminationDirect torch into one pupil and note constrictionDirect torch into one pupil and note constrictionQuickly move to contra-lateral pupil note the Quickly move to contra-lateral pupil note the reactionreactionRepeat this to and fro swinging, rhythmically, Repeat this to and fro swinging, rhythmically, several times while observing responseseveral times while observing responseNormally both pupils constrict equallyNormally both pupils constrict equallyIn presence of rapid afferent pupillary defect In presence of rapid afferent pupillary defect (RAPD) or Marcus Gunn pupil, the affected pupil (RAPD) or Marcus Gunn pupil, the affected pupil shows a reduced amplitude of constriction and shows a reduced amplitude of constriction and accelerated dilatation (recovery) as compared to accelerated dilatation (recovery) as compared to contralateral eyecontralateral eye
Pupillary reactionsPupillary reactions
Near reflex- pupil contracts while Near reflex- pupil contracts while looking at near object. It has 2 parts looking at near object. It has 2 parts – –
a) convergence reflex i.e. a) convergence reflex i.e. contraction of pupil on convergencecontraction of pupil on convergence
b) accommodation reflex i.e. b) accommodation reflex i.e. contraction on accommodationcontraction on accommodation
EXAMINATION OF LENSEXAMINATION OF LENS
EXAMINATION OF LENSEXAMINATION OF LENS
Lens is a transparent biconvex Lens is a transparent biconvex structure, placed in the patellar structure, placed in the patellar fossa, suspended by suspensory fossa, suspended by suspensory zonules.zonules.
Abnormalities may be related to Abnormalities may be related to Shape, position, colour and Shape, position, colour and transparency transparency
Abnormality of shape Abnormality of shape
Shape- Lenticonus: there may be Shape- Lenticonus: there may be anterior or posterior conical bulge, anterior or posterior conical bulge, accordingly it is called anterior or accordingly it is called anterior or posterior lenticonus.posterior lenticonus.
Spherophakia: small globular lensSpherophakia: small globular lens
Coloboma: a notch at periphery of Coloboma: a notch at periphery of lenslens
Position of LensPosition of Lens Dislocation- lens is not present in normal Dislocation- lens is not present in normal
position and all its suspensary ligaments are position and all its suspensary ligaments are broken. Anterior dislocation is into anterior broken. Anterior dislocation is into anterior chamber, posterior dislocation is into the chamber, posterior dislocation is into the vitreous cavity where it may be vitreous cavity where it may be floating( lensa nutans) or fixed to retina floating( lensa nutans) or fixed to retina (lensa fixata)(lensa fixata)
Subluxation- lens is partially displaced from Subluxation- lens is partially displaced from its position. Zonules are intact in some its position. Zonules are intact in some quadrants and broken in other. With dilated quadrants and broken in other. With dilated pupil the edge of the subluxated lens is seen pupil the edge of the subluxated lens is seen as a golden as a golden system system on focal illumination.on focal illumination.
Aphakia and PseudophakiaAphakia and Pseudophakia
Aphakia- absence of crystalline lens. Aphakia- absence of crystalline lens. Diagnosed by jet black pupil, deep anterior Diagnosed by jet black pupil, deep anterior chamber, hypermetropic eye on chamber, hypermetropic eye on ophthalmoscopy and absence of third & ophthalmoscopy and absence of third & fourth Purkinge images.fourth Purkinge images.
Pseudophakia – when crystalline lens is Pseudophakia – when crystalline lens is removed and artificial lens is implanted in removed and artificial lens is implanted in posterior chamber or at iris plane or in posterior chamber or at iris plane or in anterior chamber it is called pseudophakia. anterior chamber it is called pseudophakia. When posterior chamber IOL is present a When posterior chamber IOL is present a plastic reflex (shinning reflex) is obtained on plastic reflex (shinning reflex) is obtained on throwing light into the pupillary area.throwing light into the pupillary area.
Crystalline LensCrystalline Lens
Colour – in young age normal lens has Colour – in young age normal lens has a bluish huea bluish hue
In old age – grayish In old age – grayish
In immature cataract – grayish white In immature cataract – grayish white
Pearly white in mature cataract, and Pearly white in mature cataract, and milky white in hypermature cataract.milky white in hypermature cataract.
Transparency- any opacity in lens is Transparency- any opacity in lens is called cataract. On distant direct called cataract. On distant direct ophthalmoscopy the lenticular opacities ophthalmoscopy the lenticular opacities appear black against a red reflex. appear black against a red reflex.
Immature Cataract Immature Cataract
Intumescent Cataract Intumescent Cataract
PC IOLPC IOL
AC IOLAC IOL
top related