Examination of Eye

Examination of Anterior Segment Part - II

Examination of Cornea
Examination of cornea is done under the following headings 1. Shape 2. Size 3. Surface 4. Transparency 5. Corneal Sensation

Uniocular Loupe

Examination of Cornea
Size Normal Diameter Horizontal 11 mm Vertical 10.6 mm Size Measured by Transparent rule Slit Lamp

Corneal Size
Size Increased - Megalocornea - Buphthalmos - Keratoglobus Size Decreased : - Microcornea - Microphthalmos

Corneal Shape
Shape of Cornea Normal cornea is elliptical with regular curvature. Examined by help of slit beam on slit lamp.

Curvature
Flat Cornea : Cornea plateau Atrophic bulbi Conical Cornea : Keratoconus Globular Cornea : Keratoglobus Anterior staphyloma Buphthalmos

Corneal Surface
Surface : Corneal surface is normally smooth regular Examined with the help of placido disk reflex, window reflex, corneal staining or sophisticated corneal topography machine.

Corneal Surface
Placido Disk : Hold the disk in front of the patient cornea and look through the lens in centre of disk at patients cornea. The image of disc (circles) is seen on patient cornea if they are regular surface is smooth and regular.

Corneal Transparency
Transparency of Cornea : Normal cornea is uniformly transparent Hazy in : Corneal edema due to Keratits Bullous Keratopathy. Glaucoma (Acute Congestive) Iridocyctitis Acute hydrops Corneal dystrophy.

Corneal edema in Angle Closure Glaucoma

Corneal Ulcer

Corneal Opacity
Corneal Opacity : Opacity should be examine under following head 1. Number of opacity 2. Size and shape 3. Site 4. Type 5. Vascularization

Corneal Opacity
Type of Corneal Opacity : Nebular Iris details clearly visible at level of anterior stroma and Bowman membrane. Macular Iris details visible, of stroma. Leucomatous No iris details are visible. The whole stroma is involved

Nebulomacular Corneal Opacity

Leucomatous Corneal Opacity

Leucomatous Corneal Opacity

Corneal Edema

Corneal Opacity
Leucomatous corneal opacity may be seen in association with Anterior Synechia Adherent Leucoma Corneoiridic scar Opacity also looked for any abnormal pigmentation and degeneration.

Salzman Nodular Degeneration

Vascularization of Cornea
Superficial 1. Vessel can be traced over limbus into conjunctiva 2. Sup. vessels are bright red & well defined Sup. vessels branch dichotomously in an arborescent fashion Sup. vessels raise the epithelium over them so corneal surface is uneven Deep 1. Deep vessel end abruptly at the limbus 2. 3. Ill defined purplish red or red bluish Deep vessels run parallel. Branch acute angle and their course is determined by lamellar structure of cornea.

3.

4.

4.

Cornea is smooth and hazy.

Superficial Vascularization

Corneal Sensation
Method : Patient is asked to see forward. A whisp of cotton is touched to cornea on temporal side, nasal, superior, inferior and central regions and observe for blinking of eye. Decreased Corneal Sensation, seen in : - Herpes simplex, - Lesion of 5th nerve - Herpes zoster - Keratomalacia - Absolute glaucoma - Leprosy

Keratic Precipitation (K.P.)

These are deposits of inflammatory cells on the endothelium of cornea. - Fine K.P. - Mutton fat K.P. - Pigmented K.P. (old) Cause Iridocyclitis

Ciliary Congestion + KPs in a case of Iridocyclitis

Slit lamp

Slit Lamp Examination

Technique of examination of cornea on slit lamp
1. 2. 3. 4. 5. 6. Diffuse illumination Direct focal illumination Indirect illumination Retroillumination Sclerotic Scatter Specular Microscopy

Sclera

Is white tough outer coat of eye with protective function. This structure is avascular, dense fibrous tissue covered anteriorly by conjunctiva Sclera is examined by asking the patient to up, down, medially and laterally by holding the lids to have maximum view

Blue sclera

Abnormalities of Sclera
1.

2.
3.

Nodule Thinning / pigmentation Ectasia

Episcleritis

Examination of Ant. Chamber

Depth of A.C. Contents of A.C. Normal depth of anterior chamber is 2.5 mm Depth Examine by slit beam on slit tamp or by oblique torch light (rough idea) Anterior chamber may be normal, shallow or deep in depth

Shallow AC
Causes of shallow depth of anterior chamber Hypermetropic eye Microcornea Flat cornea Narrow angle glaucoma Intumescent cataract Traumatic cataract Ant. dislocation of lens Choroidal detachment Over filtering bleb Malignant glaucoma

Deep Anterior Chamber

Causes of Deep Anterior Chamber Infants High Myopia Keratoglobus Keratoconus Buphthalmos. Aphakia Post dislocation of lens Total post synechia

Irregular depth of Anterior Chamber

Causes Subluxation of lens Iris bombe Adherent leucoma Traumatic cataract Tumor of iris and cilliary body.

Abnormal Contents of AC

Cells (in uveitis ) inflammatory cell in AC Examined by conical beam of slit lamp Aqueous flare Protein in AC Hypopyon Pus in anterior chamber Hypopyon may be mobile or solid fixed Hyphema blood in A.C. Cortical lens matter Anterior chamber IOL Foreign body

Hypaema

Hypopyon

Angle of Anterior Chamber

Angle of anterior chamber is examined with Gonioscope (procedure is called Gonioscopy) Structures forming angle of anterior chamber are: 1. Root of Iris 2. Ciliary body band 3. Scleral spur 4. Trabecular Meshwork 5. Schwalbe line

Anatomy of Angle of AC

Sketch by Dr Shikha

GONIOSCOPIC VIEW

Sketch by Dr Shikha

Examination of Iris

Points examined in Iris are

1.

2.
3. 4.

5.
6. 7. 8. 9.

Colour of Iris Pattern of iris Any adhesions of Iris Persistant pupillary membrane Iridodonesis Rubeosis Iridis Coloboma of Iris Iridodialysis Aniridia

Colour of Iris

Colour: varies in different races. Normally dark brown in Orientals. Light blue or green in Caucasians. Other variations in colour: Congenital heterochromia iridumdifference in colour of the two irises. Heterochromia iridis- difference in colour of sectors of the same iris. Greyish atrophic patches in healed iridocyclitis Darkly pigmented spots (naevi)

Normal Pattern of Iris

Note Iris Colour & Pattern

Healed Iridocyclitis

Post Laser Iridotomy

Pattern of Iris

Pattern: Normal pattern consists of a collarets dividing iris into papillary & ciliary zone, and ridges and crypts. Muddy Iris- disturbance of normal pattern in acute iridocyclitis. Atrophic patches- in healed iridocyclitis Sectoral patches of atrophy- acute angle closure glaucoma, herpes zoster iritis. Brushfield spots- Downs syndrome Pedunculated nodules- Lisch nodules in neurofibromatosis Flat nodules at papillary margin- Koeppe nodules Flat nodules at peripheral base of iris- Busacca nodules

Synechiae

Persistent pupillary membraneabnormal congenital tags of iris tissue adherent to collarette. Synechiae- adhesion of iris to other intraocular structures Anterior synechiae- to posterior surface of cornea Posterior synechiae- to anterior surface of lens. They may beSegmental, total or annular.

Iridocyclitis

Posterior Synechia

Other Abnormalities

Iridodonesis- tremulousness of iris due to loss of posterior support of lens in aphakia or subluxation of lens. Rubeosis iridis- new vessels on surface of iris in diabetes mellitus, central retinal vein occlusion, chronic iridocyclitis. Coloboma- gap or hole in iris Iridodialysis- separation of iris from ciliary body. Aniridia- complete absence of iris

Iridodialysis

Coloboma of Iris

Examination of Pupil

Pupils

Pupil is the circular aperture in the centre of iris. Its normal size is 34mm. it is grayish black in colour.

Points to be noted in pupil

1. Number-normally there is one pupil. More than one pupil is called polycoria. 2. Location- normally almost central, slightly nasal. Eccentric pupil is called correctopia. 3. Size of pupils

Pupillary size

Size- 3-4 mm normal, depending on illumination Causes of abnormally small pupil - miosis Local miotic Drugs (parasympathomimetic) Systemic morphine Iridocyclitis- narrow, irregular, non-reacting pupil Morphine Horners syndrome Head injury (pontine hemorrhage) Senile miotic pupil Effect of strong light During sleep

Dilated pupil

Causes of abnormally dilated pupil - mydriasis Sympathomimetic drugs- adrenaline, phenilephrine Parasympatholytic drugs- atropine, homatropine, cyclopentolate, tropicamide Acute congestive glaucoma (vertically oval, immobile pupil) Absolute glaucoma Optic atrophy Retinal detachment Internal ophthalmoplegia 3rd nerve paralysis Belladonna poisoning

Note Dilated pupil of Left eye

Shape of pupil

Shape normally circular Irregular narrow pupil- iridocyclitis Festooned pupil- irregular pupil after patchy dilatation (effect of mydriatics in presence of posterior synechiae)

Pupillary reactions

Pupillary Reflexes Light reflex- Direct- throw light into the eye, look for pupillary constriction in the same eye Consensual - keep an obstruction between the two eyes. Throw light in one eye, look for constriction in other eye.

Yellow reflex in pupillary area

Irregular pupil in a case of iridocyclitis

Pupillary reactions

Swinging flash light test - patient is made to sit in a room with diffuse background illumination Direct torch into one pupil and note constriction Quickly move to contra-lateral pupil note the reaction Repeat this to and fro swinging, rhythmically, several times while observing response Normally both pupils constrict equally In presence of rapid afferent pupillary defect (RAPD) or Marcus Gunn pupil, the affected pupil shows a reduced amplitude of constriction and accelerated dilatation (recovery) as compared to contralateral eye

Pupillary reactions

Near reflex- pupil contracts while looking at near object. It has 2 parts a) convergence reflex i.e. contraction of pupil on convergence b) accommodation reflex i.e. contraction on accommodation

EXAMINATION OF LENS

EXAMINATION OF LENS

Lens is a transparent biconvex structure, placed in the patellar fossa, suspended by suspensory zonules. Abnormalities may be related to Shape, position, colour and transparency

Abnormality of shape
Shape- Lenticonus: there may be anterior or posterior conical bulge, accordingly it is called anterior or posterior lenticonus. Spherophakia: small globular lens Coloboma: a notch at periphery of lens

Position of Lens

Dislocation- lens is not present in normal position and all its suspensary ligaments are broken. Anterior dislocation is into anterior chamber, posterior dislocation is into the vitreous cavity where it may be floating( lensa nutans) or fixed to retina (lensa fixata) Subluxation- lens is partially displaced from its position. Zonules are intact in some quadrants and broken in other. With dilated pupil the edge of the subluxated lens is seen as a golden system on focal illumination.

Aphakia and Pseudophakia

Aphakia- absence of crystalline lens. Diagnosed by jet black pupil, deep anterior chamber, hypermetropic eye on ophthalmoscopy and absence of third & fourth Purkinge images. Pseudophakia when crystalline lens is removed and artificial lens is implanted in posterior chamber or at iris plane or in anterior chamber it is called pseudophakia. When posterior chamber IOL is present a plastic reflex (shinning reflex) is obtained on throwing light into the pupillary area.

Crystalline Lens
Colour in young age normal lens has a bluish hue In old age grayish In immature cataract grayish white Pearly white in mature cataract, and milky white in hypermature cataract. Transparency- any opacity in lens is called cataract. On distant direct ophthalmoscopy the lenticular opacities appear black against a red reflex.

Immature Cataract

Intumescent Cataract

PC IOL

AC IOL