This document summarizes a lecture on examination of the anterior segment of the eye. It describes examining the cornea for size, shape, surface, transparency and sensation. It details evaluating the anterior chamber depth and contents. It also outlines examining the iris for color, pattern, adhesions and other abnormalities. The goal is to teach junior medical students the techniques for anterior segment examination.
This document summarizes a lecture on examination of the anterior segment of the eye. It describes examining the cornea for size, shape, surface, transparency and sensation. It details evaluating the anterior chamber depth and contents. It also outlines examining the iris for color, pattern, adhesions and other abnormalities. The goal is to teach junior medical students the techniques for anterior segment examination.
This document summarizes a lecture on examination of the anterior segment of the eye. It describes examining the cornea for size, shape, surface, transparency and sensation. It details evaluating the anterior chamber depth and contents. It also outlines examining the iris for color, pattern, adhesions and other abnormalities. The goal is to teach junior medical students the techniques for anterior segment examination.
Part - II Copy of Lecture taken by Dr Sanjay Shrivastava Professor of Ophthalmology for Junior Final year students of Gandhi Medical College, Bhopal 18-Jun-14 Prof Sanjay Shrivastava 2 Examination of Cornea Examination of cornea is done under the following headings 1. Shape 2. Size 3. Surface 4. Transparency 5. Corneal Sensation 18-Jun-14 Prof Sanjay Shrivastava 3 Uniocular Loupe 18-Jun-14 Prof Sanjay Shrivastava 4 Examination of Cornea Size Normal Diameter Horizontal 11 mm Vertical 10.6 mm Size Measured by Transparent rule Slit Lamp 18-Jun-14 Prof Sanjay Shrivastava 5 Corneal Size Size Increased - Megalocornea - Buphthalmos - Keratoglobus Size Decreased : - Microcornea - Microphthalmos 18-Jun-14 Prof Sanjay Shrivastava 6 Corneal Shape Shape of Cornea Normal cornea is elliptical with regular curvature. Examined by help of slit beam on slit lamp. 18-Jun-14 Prof Sanjay Shrivastava 7 Curvature Flat Cornea : Cornea plateau Atrophic bulbi Conical Cornea : Keratoconus Globular Cornea : Keratoglobus Anterior staphyloma Buphthalmos 18-Jun-14 Prof Sanjay Shrivastava 8 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. 18-Jun-14 Prof Sanjay Shrivastava 9 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. 18-Jun-14 Prof Sanjay Shrivastava 10 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. 18-Jun-14 Prof Sanjay Shrivastava 11 Corneal edema in Angle Closure Glaucoma 18-Jun-14 Prof Sanjay Shrivastava 12 Corneal Ulcer 18-Jun-14 Prof Sanjay Shrivastava 13 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 18-Jun-14 Prof Sanjay Shrivastava 14 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
18-Jun-14 Prof Sanjay Shrivastava 15 Nebulomacular Corneal Opacity 18-Jun-14 Prof Sanjay Shrivastava 16 Leucomatous Corneal Opacity 18-Jun-14 Prof Sanjay Shrivastava 17 Leucomatous Corneal Opacity 18-Jun-14 Prof Sanjay Shrivastava 18 Dry Eye with Corneal Opacity 18-Jun-14 Prof Sanjay Shrivastava 19 Corneal Edema 18-Jun-14 Prof Sanjay Shrivastava 20 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.
18-Jun-14 Prof Sanjay Shrivastava 21 18-Jun-14 Prof Sanjay Shrivastava 22 Salzman Nodular Degeneration 18-Jun-14 Prof Sanjay Shrivastava 23 Vascularization of Cornea Superficial 1. Vessel can be traced over limbus into conjunctiva
2. Sup. vessels are bright red & well defined 3. Sup. vessels branch dichotomously in an arborescent fashion
4. Sup. vessels raise the epithelium over them so corneal surface is uneven Deep 1. Deep vessel end abruptly at the limbus
2. Ill defined purplish red or red bluish 3. Deep vessels run parallel. Branch acute angle and their course is determined by lamellar structure of cornea.
4. Cornea is smooth and hazy. 18-Jun-14 Prof Sanjay Shrivastava 24 Superficial Vascularization 18-Jun-14 Prof Sanjay Shrivastava 25 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 5 th nerve - Herpes zoster - Keratomalacia - Absolute glaucoma - Leprosy 18-Jun-14 Prof Sanjay Shrivastava 26 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 18-Jun-14 Prof Sanjay Shrivastava 27 Ciliary Congestion + KPs in a case of Iridocyclitis 18-Jun-14 Prof Sanjay Shrivastava 28 Slit lamp 18-Jun-14 Prof Sanjay Shrivastava 29 Slit Lamp Examination Technique of examination of cornea on slit lamp 1. Diffuse illumination 2. Direct focal illumination 3. Indirect illumination 4. Retroillumination 5. Sclerotic Scatter 6. Specular Microscopy 18-Jun-14 Prof Sanjay Shrivastava 30 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 18-Jun-14 Prof Sanjay Shrivastava 31 Blue sclera 18-Jun-14 Prof Sanjay Shrivastava 32 Abnormalities of Sclera 1. Nodule 2. Thinning / pigmentation 3. Ectasia 18-Jun-14 Prof Sanjay Shrivastava 33 Episcleritis 18-Jun-14 Prof Sanjay Shrivastava 34 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 18-Jun-14 Prof Sanjay Shrivastava 35 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 18-Jun-14 Prof Sanjay Shrivastava 36 Deep Anterior Chamber Causes of Deep Anterior Chamber Infants High Myopia Keratoglobus Keratoconus Buphthalmos. Aphakia Post dislocation of lens Total post synechia 18-Jun-14 Prof Sanjay Shrivastava 37 Irregular depth of Anterior Chamber Causes Subluxation of lens Iris bombe Adherent leucoma Traumatic cataract Tumor of iris and cilliary body. 18-Jun-14 Prof Sanjay Shrivastava 38 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 18-Jun-14 Prof Sanjay Shrivastava 39 Hypaema 18-Jun-14 Prof Sanjay Shrivastava 40 Hypopyon 18-Jun-14 Prof Sanjay Shrivastava 41 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 18-Jun-14 Prof Sanjay Shrivastava 42 Anatomy of Angle of AC Sketch by Dr Shikha 18-Jun-14 Prof Sanjay Shrivastava 43 GONIOSCOPIC VIEW Sketch by Dr Shikha 18-Jun-14 Prof Sanjay Shrivastava 44 Examination of Iris 18-Jun-14 Prof Sanjay Shrivastava 45 Points examined in Iris are 1. Colour of Iris 2. Pattern of iris 3. Any adhesions of Iris 4. Persistant pupillary membrane 5. Iridodonesis 6. Rubeosis Iridis 7. Coloboma of Iris 8. Iridodialysis 9. Aniridia
18-Jun-14 Prof Sanjay Shrivastava 46 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 iridum- difference 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) 18-Jun-14 Prof Sanjay Shrivastava 47 Normal Pattern of Iris 18-Jun-14 Prof Sanjay Shrivastava 48 Note Iris Colour & Pattern 18-Jun-14 Prof Sanjay Shrivastava 49 Healed Iridocyclitis 18-Jun-14 Prof Sanjay Shrivastava 50 Iris Coloboma with Cataract 18-Jun-14 Prof Sanjay Shrivastava 51 Post Laser Iridotomy 18-Jun-14 Prof Sanjay Shrivastava 52 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 18-Jun-14 Prof Sanjay Shrivastava 53 Synechiae Persistent pupillary membrane- abnormal 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 be- Segmental, total or annular. 18-Jun-14 Prof Sanjay Shrivastava 54 Iridocyclitis 18-Jun-14 Prof Sanjay Shrivastava 55 Posterior Synechia 18-Jun-14 Prof Sanjay Shrivastava 56 Healed iridocyclitis 18-Jun-14 Prof Sanjay Shrivastava 57 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 18-Jun-14 Prof Sanjay Shrivastava 58 Iridodialysis 18-Jun-14 Prof Sanjay Shrivastava 59 Coloboma of Iris 18-Jun-14 Prof Sanjay Shrivastava 60 Examination of Pupil 18-Jun-14 Prof Sanjay Shrivastava 61 Pupils Pupil is the circular aperture in the centre of iris. Its normal size is 3-4mm. it is grayish black in colour. 18-Jun-14 Prof Sanjay Shrivastava 62 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 18-Jun-14 Prof Sanjay Shrivastava 63 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 18-Jun-14 Prof Sanjay Shrivastava 64 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 18-Jun-14 Prof Sanjay Shrivastava 65 Note Dilated pupil of Left eye 18-Jun-14 Prof Sanjay Shrivastava 66 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) 18-Jun-14 Prof Sanjay Shrivastava 67 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. 18-Jun-14 Prof Sanjay Shrivastava 68 Yellow reflex in pupillary area 18-Jun-14 Prof Sanjay Shrivastava 69 Irregular pupil in a case of iridocyclitis 18-Jun-14 Prof Sanjay Shrivastava 70 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 18-Jun-14 Prof Sanjay Shrivastava 71 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 18-Jun-14 Prof Sanjay Shrivastava 72 EXAMINATION OF LENS 18-Jun-14 Prof Sanjay Shrivastava 73 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
18-Jun-14 Prof Sanjay Shrivastava 74 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 18-Jun-14 Prof Sanjay Shrivastava 75 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. 18-Jun-14 Prof Sanjay Shrivastava 76 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. 18-Jun-14 Prof Sanjay Shrivastava 77 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. 18-Jun-14 Prof Sanjay Shrivastava 78 Congenital Cataract 18-Jun-14 Prof Sanjay Shrivastava 79 Immature Cataract 18-Jun-14 Prof Sanjay Shrivastava 80 Advanced Immature Cataract 18-Jun-14 Prof Sanjay Shrivastava 81 Immature Cataract 18-Jun-14 Prof Sanjay Shrivastava 82 Aphakia 18-Jun-14 Prof Sanjay Shrivastava 83 Traumatic Cataract 18-Jun-14 Prof Sanjay Shrivastava 84 Pseudophakia 18-Jun-14 Prof Sanjay Shrivastava 85 Intumescent Cataract 18-Jun-14 Prof Sanjay Shrivastava 86 PC IOL with Capture 18-Jun-14 Prof Sanjay Shrivastava 87 PC IOL with Capture 18-Jun-14 Prof Sanjay Shrivastava 88 PC IOL 18-Jun-14 Prof Sanjay Shrivastava 89 AC IOL
OCULOPATHY - Disproves the orthodox and theoretical bases upon which glasses are so freely prescribed, and puts forward natural remedial methods of treatment for what are sometimes termed incurable visual defects