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