Ophthal examination of eye

Examination of eye- External Examination, Fundus examination, Visual field examination

1. Examination of Eye - Reshma Ann Mathew

2. External Examination of eye Fundus Examination Visual field examination

3. External Examination Examination of- Iris Pupil Lens Intra-ocular pressure (IOP)

4. Examination of IRIS COLOUR – Light blue or green in Caucasians and Dark brown in orientals Heterochromia iridium - different colour of 2 iris Heterochromia iridis -different colour of sectors of the same iris It occurs due to involved iris being lighter or darker than the normal

5. Iris lighter than normal- congenital heterochromia, atrophic patches in chronic uveitis, metastatic carcinoma

6. Iris darker than normal- Iris naevi -appear as freckles ocular melanocytosis , haemosiderosis , siderosis bulbi, retained iris foreign body, malignant melanoma of iris lymphoma

7. PATTERN OF NORMAL IRIS Pattern occurs due to presence of collarette , crypts and radial striations on its anterior surface It is disturbed in Acute iridocyclitis - muddy iris Healed iridocyclitis - atrophy of iris PERSISTENT PUPILLARY MEMBRANE It is seen as abnormal congenital tags of iris tissue adherent to the collarette area

8. SYNECHIAE It is the adhesion of iris to other intraocular structures Types- Anterior - in Adherent leucoma Posterior - in Iridocyclitis ; can be total, annular or segmental IRIDODONESIS It is the tremulousness (trembling) of the iris Seen in aphakia and subluxation of lens (since posterior support is lost)

9. NODULES ON THE IRIS SURFACE Seen in granulomatous uveitis, melanoma, tuberculoma and gumma of iris RUBEOSIS IRIDIS New vessel formation on the iris Seen in diabetic retinopathy, central retinal vein occlusion, chronic uveitis, chronic retinal detachment, retinoblastoma

10. GAP OR HOLE IN THE IRIS May be due to congenital coboloma or due to iridectomy (surgical coboloma ) Iridodialysis -separation of iris from ciliary body ANIRIDIA OR IRIDEREMIA Complete absence of iris Rare congenital condition IRIS CYST In patients using strong miotic drops , it may be seen in the pupillary margin

11. Examination of PUPIL NUMBER Normal: 1 pupil Rarely: more than 1 pupil ( polycoria ) LOCATION Normal: almost centre of the iris, slightly nasal Rarely: congenitally eccentric ( corectopia ) SIZE Normal: 3-4mm depending upon illumination It may be abnormally small ( miosis ) or large( mydriasis ) Anisocoria - It is a condition where there is difference between the size of two pupils

12. Causes of Miosis Effect of local miotic drugs- Parasympathomimetic drugs Iridocyclitis -narrow, irregular, non-reacting pupil Head injury- pontine haemorrhage Senile rigid miotic pupil Due to effect of strong light During sleep pupil is pinpoint

13. Causes of Mydriasis Effect of topical sympathomimetic drugs-Adrenaline, phenylephrine Effect of topical parasympatholytic drugs-Atropine, homatropine , tropicamide , cyclopentolate Acute congestive glaucoma Absolute glaucoma

14. SHAPE Normal: circular Irregular narrow - iridocyclitis Festooned - effect of mydriatics on posterior segment synechiae Vertically oval / pear shaped/ updrawn - postoperatively (due to incarceration of iris or vitreous in the wound at 12 o’clock postion )

15. COLOUR Normal: greyish black Aphakia - jet black Immature senile cortical cataract- greyish white Mature cortical cataract- pearly white Hypermature cataract- milky white Cataracta brunescens - brown Cataracta nigra - brownish black Leucocoria - white reflex in pupil Glaucoma- greenish hue Iridocyclitis - dirty white exudates

16. PUPILLARY REACTIONS Direct light reflex- Normal: pupil reacts briskly and constricts Consensual light reflex Normal: contralateral pupil should also constrict

17. Swinging flash light test -(when RAPD is suspected) Normal: both pupils constrict equally and the pupil to which light is transferred remains tightly constricted RAPD present: affected pupil will dilate when flash light is moved from normal eye to abnormal eye. This is called Marcus Gunn Pupil Near reflex - Pupil constricts while looking at a near object

18. Abnormal pupillary reactions are seen in Amaurotic pupil Efferent pathway defect Wernicke’s hemianopic pupil Marcus Gunn pupil Argyll Robertson pupil Tonic pupil

19. Examination of LENS Can be examined using oblique illumination , slit lamp biomicroscopy and distant direct ophthalmoscopy with FULLY DILATED PUPILS POSITION Normal: patellar fossa by the zonules Dislocation of lens: lens not present in its normal position Anterior dislocation-present in anterior chamber Posterior dislocation-present in vitreous cavity either floating (LENSA NUTANS) or fixed to the retina(LENSA FIXATE)

20. Subluxation of lens-lens is partially displaced from its position Causes- trauma, marfan’s syndrome, homocystinuria Aphakia - absence of lens It is diagnosed by jet black pupil , deep anterior chamber, empty patellar fossa by slit lamp biomicroscopy hypermetropic eye on ophthalmoscopy, retinoscopy ABSENCE of 3 rd and 4 th purkinje images Pseudophakia - When posterior chamber IOL is present , it is diagnosed by black pupil, deep anterior chamber, shining reflexes (from anterior surface of IOL) and PRESENCE of all the four Purkinje images

21. SHAPE Normal: biconvex structure, on slit lamp-optical section shows embryonic, foetal, infantile and adult nuclei, cortex and capsule Spherophakia -spherical Lenticonus anterior -anterior cone shaped bulge ( Alport syndrome) Lenticonus posterior -posterior cone shaped bulge Coloboma of lens-Notch in the lens

22. Colour Normal: In young age, it is almost clear or gives a faint blue hue Old age- greyish white (mistaken to be cataract) CORTICAL cataract- greyish white (immature), pearly white (mature), milky white ( hypermature ) NUCLEAR cataract- amber, brown or black Cataractous lens with siderosis bulbi- rusty (orange)

23. TRANSPARENCY Normal: transparent Any opacity in the lens is called CATARACT Complicated cataract-breadcrumb appearance ( polychromatic lustre ) True diabetic cataract- snow flake opacities Wilson’s disease- sunflower cataract Concussion injury of lens- rosette shaped cataract

24. DEPOSITS ON ANTERIOR SURFACE OF LENS - Vossius ring -in blunt trauma Pigmented clumps - iridocyclitis Dirty white exudates -uveitis, endophthalmitis Rusty deposits - siderosis bulbi (deposition of ferrous ions) Greenish deposits - chalcosis (deposition of copper ions)

25. PURKINJE IMAGES TEST It WAS used to diagnose mature cataract and aphakia Normal- When a strong beam of light is shown to the eye, 4 images ( purkinje images) are formed from the four different reflecting surfaces [ ant & post surfaces of cornea and lens ] Mature cataract- 4 th image is absent (post surface of lens) Aphakia - 3 rd and 4 th are absent (ant & post surface of lens)

26. Intraocular pressure Digital tonometry- IOP raised -fluctuation produced is feeble or absent, eyeball- firm to hard IOP low -eyeball- soft Indentation and Applanation tonometers are frequently used Normal IOP= 10-21 mm Hg Hypotony - IOP < 10 mm Hg Causes-ruptured globe, retinal/choroidal detachment, postoperative wound leak Glaucoma suspected when IOP >21 mm Hg

27. Fundus Examination To diagnose diseases of vitreous , optic nerve head , retina and choroid For thorough examination, pupils to be dilated with 5%phenylephrine and/or 1%tropicamide eye drops

28. Techniques of Fundus Examination Ophthalmoscopy Distant direct ophthalmoscopy Direct ophthalmoscopy Indirect ophthalmoscopy Slit lamp bio-microscopic examination by Indirect slit lamp bio-microscopy Hruby lens bio-microscopy Contact lens bio-microscopy

29. OCULAR MEDIA Normal- transparent Opacities- black against red glow (distant direct ophthalmoscopy) Causes-corneal opacity, lenticular opacity, vitreous opacity

30. OPTIC DISC SIZE: normal- 1.5 mm; hypermetropes -smaller; myopes -larger SHAPE: normal- circular ; high astigmatism-oblong MARGINS: normal- well defined ; blurring of margins- papilloedema , papillitis COLOUR: normal- pinkish with central pallor ; Hyperaemia- papilloedema Pale-partial optic atrophy Chalky white-primary optic atrophy Yellow waxy-consecutive optic atrophy

31. CUP DISC RATIO: Normal- 0.3 ; Large cup-physiological or glaucomatous; Cup full- papilloedema , papillitis SPLINTER HAEMORRHAGES: seen in primary open angle glaucoma, papilloedema NEOVASCULARISATION: diabetic retinopathy PERIPAPILLARY CRESENT: myopia

32. MACULA Situated at posterior pole with its centre (foveolar ) about 2 disc diameters lateral to temporal margin of disc Normal- slightly darker than surrounding retina, its centre imparts a bright reflex- foveal reflex Abnormalities- MACULAR HOLE MACULAR HAEMORRHAGE CHERRY RED SPOTS- Neimann Pick’s disease, Gaucher’s disease, central retinal artery occlusion MACULAR OEDEMA- trauma, intraocular operations

33. PIGMENTARY DISTURBANCES- after trauma, solar burn, chloroquine toxicity BULL’S EYE MACULAR LESIONS- age related macular degeneration, chloroquine retinopathy HARD EXUDATES-hypertensive retinopathy, exudative diabetic maculopathy MACULAR SCARRING- trauma, disciform macular degeneration

34. RETINAL BLOOD VESSELS Normal: arterioles-bright red , veins-purplish Abnormalities- NARROWING OF ARTERIOLES-hypertensive retinopathy, arteriosclerosis, central retinal artery occlusion TORTUOSITY OF VEINS-diabetes mellitus, central retinal vein occlusion SHEATHING OF VESSELS-hypertensive retinopathy VASCULAR PULSATIONS- venous pulsations (seen normally in some), arterial pulsations ( seen in patients with aortic regurgitation, aneurysm, exophthalmic goitre)

35. GENERAL BACKGROUND Normal- pinkish red Abnormal- SUPERFICIAL RETINAL HAEMORRHAGES-hypertension, diabetes, trauma DEEP RETINAL HAEMORRHAGES-diabetic retinopathy COTTON WOOL SPOTS(SOFT EXUDATES)- hypertensive retinopathy, diabetic retinopathy, anaemias, collagen disorders HARD EXUDATES-Hypertensive retinopathy, diabetic retinopathy COLLOID BODIES-senile macular degeneration PIGMENTARY DISTURBANCES-retinitis pigmentosa

36. MICROANEURYSMS-diabetic retinopathy NEOVASCULARISATION of retina- diabetic retinopathy, sickle cell retinopathy TUMOURS of fundus-retinoblastoma PERIPHERAL RETINAL DEGENERATION RETINAL HOLES PROLIFERATIVE RETINOPATHY RETINAL DETACHMENT

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