Examination of Eye

-RESHMA ANN MATHEW

External Examination of eyeFundus ExaminationVisual field examination

External Examination

Examination of-• Iris• Pupil• Lens

Intra-ocular pressure (IOP)

Examination of IRISCOLOUR –

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

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

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

PATTERN OF NORMAL IRISo Pattern occurs due to presence of collarette, crypts and radial

striations on its anterior surfaceo It is disturbed in

i. Acute iridocyclitis-muddy irisii. Healed iridocyclitis-atrophy of iris

PERSISTENT PUPILLARY MEMBRANEo It is seen as abnormal congenital tags of iris tissue adherent to the collarette area

SYNECHIAEo It is the adhesion of iris to other intraocular structureso Types-

i. Anterior- in Adherent leucomaii. Posterior- in Iridocyclitis; can be total, annular or

segmentalIRIDODONESIS

o It is the tremulousness(trembling) of the iriso Seen in aphakia and subluxation of lens (since posterior

support is lost)

NODULES ON THE IRIS SURFACEo Seen in granulomatous uveitis, melanoma, tuberculoma and gumma of iris

RUBEOSIS IRIDISo New vessel formation on the iriso Seen in diabetic retinopathy, central retinal vein occlusion,

chronic uveitis, chronic retinal detachment, retinoblastoma

GAP OR HOLE IN THE IRISo May be due to congenital coboloma or due to iridectomy(surgical

coboloma)o Iridodialysis-separation of iris from ciliary body

ANIRIDIA OR IRIDEREMIAo Complete absence of iriso Rare congenital condition

IRIS CYSTo In patients using strong miotic drops, it may be seen in the pupillary margin

Examination of PUPIL NUMBER

o Normal: 1 pupilo Rarely: more than 1 pupil (polycoria)

LOCATIONo Normal: almost centre of the iris, slightly nasalo Rarely: congenitally eccentric (corectopia)

SIZEo Normal: 3-4mm depending upon illuminationo It may be abnormally small (miosis) or large(mydriasis)o Anisocoria- It is a condition where there is difference between the size of two pupils

o 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

o Causes of Mydriasis• Effect of topical sympathomimetic drugs-Adrenaline,

phenylephrine• Effect of topical parasympatholytic drugs-Atropine,

homatropine, tropicamide, cyclopentolate• Acute congestive glaucoma• Absolute glaucoma

SHAPEo Normal: circularo Irregular narrow- iridocyclitiso Festooned- effect of mydriatics on posterior segment synechiae

o Vertically oval/pear shaped/updrawn- postoperatively (due to incarceration of iris or vitreous in the wound at 12 o’clock postion)

COLOURo Normal: greyish blacko Aphakia-jet blacko Immature senile cortical cataract-greyish whiteo Mature cortical cataract-pearly whiteo Hypermature cataract-milky whiteo Cataracta brunescens-browno Cataracta nigra-brownish blacko Leucocoria-white reflex in pupilo Glaucoma-greenish hueo Iridocyclitis-dirty white exudates

PUPILLARY REACTIONSo Direct light reflex-

Normal: pupil reacts briskly and constricts

o Consensual light reflexNormal: contralateral pupil should also constrict

o 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

o Near reflex- Pupil constricts while looking at a near object

Abnormal pupillary reactions are seen ini. Amaurotic pupilii. Efferent pathway defectiii. Wernicke’s hemianopic pupiliv. Marcus Gunn pupilv. Argyll Robertson pupilvi. Tonic pupil

Examination of LENSCan be examined using oblique illumination, slit lamp

biomicroscopy and distant direct ophthalmoscopy with FULLY DILATED PUPILS

POSITIONo Normal: patellar fossa by the zonuleso Dislocation of lens: lens not present in its normal position

i. Anterior dislocation-present in anterior chamberii. Posterior dislocation-present in vitreous cavity either

floating(LENSA NUTANS) or fixed to the retina(LENSA FIXATE)

o Subluxation of lens-lens is partially displaced from its position• Causes-trauma, marfan’s syndrome, homocystinuria

o Aphakia-absence of lens• It is diagnosed by

i. jet black pupil, deep anterior chamber, empty patellar fossa by slit lamp biomicroscopy

ii. hypermetropic eye on ophthalmoscopy, retinoscopyiii. ABSENCE of 3rd and 4th purkinje images

o 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

SHAPEo Normal: biconvex structure, on slit lamp-optical section shows

embryonic, foetal, infantile and adult nuclei, cortex and capsuleo Spherophakia-sphericalo Lenticonus anterior-anterior cone shaped bulge (Alport

syndrome)o Lenticonus posterior-posterior cone shaped bulgeo Coloboma of lens-Notch in the lens

Colouro Normal: In young age, it is almost clear or gives a faint blue hueo Old age-greyish white (mistaken to be cataract)o CORTICAL cataract- greyish white (immature), pearly white

(mature), milky white (hypermature)o NUCLEAR cataract-amber, brown or blacko Cataractous lens with siderosis bulbi-rusty (orange)

TRANSPARENCYo Normal: transparento Any opacity in the lens is called CATARACTo Complicated cataract-breadcrumb appearance (polychromatic

lustre)o True diabetic cataract-snow flake opacitieso Wilson’s disease-sunflower cataract

o Concussion injury of lens-rosette shaped cataract

DEPOSITS ON ANTERIOR SURFACE OF LENS-o Vossius ring-in blunt traumao Pigmented clumps-iridocyclitiso Dirty white exudates-uveitis, endophthalmitiso Rusty deposits-siderosis bulbi (deposition of ferrous ions)o Greenish deposits-chalcosis(deposition of copper ions)

PURKINJE IMAGES TESTo It WAS used to diagnose mature cataract and aphakiao 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]

o Mature cataract-4th image is absent (post surface of lens)o Aphakia-3rd and 4th are absent (ant & post surface of lens)

Intraocular pressure Digital tonometry-

o IOP raised-fluctuation produced is feeble or absent, eyeball-firm to hardo IOP low-eyeball-soft

Indentation and Applanation tonometers are frequently used

Normal IOP=10-21mm Hg Hypotony- IOP < 10mm Hg

• Causes-ruptured globe, retinal/choroidal detachment, postoperative wound leak

Glaucoma suspected when IOP>21mm Hg

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

Techniques of Fundus Examination1) Ophthalmoscopy

a) Distant direct ophthalmoscopyb) Direct ophthalmoscopyc) Indirect ophthalmoscopy

2) Slit lamp bio-microscopic examination bya) Indirect slit lamp bio-microscopyb) Hruby lens bio-microscopyc) Contact lens bio-microscopy

OCULAR MEDIAo Normal- transparento Opacities-black against red glow (distant direct

ophthalmoscopy)• Causes-corneal opacity, lenticular opacity, vitreous opacity

OPTIC DISCo SIZE: normal-1.5mm; hypermetropes-smaller; myopes-largero SHAPE: normal-circular; high astigmatism-oblongo MARGINS: normal-well defined; blurring of margins-

papilloedema, papillitiso COLOUR: normal-pinkish with central pallor;

Hyperaemia-papilloedemaPale-partial optic atrophyChalky white-primary optic atrophyYellow waxy-consecutive optic atrophy

o CUP DISC RATIO: Normal-0.3; Large cup-physiological or glaucomatous; Cup full-papilloedema, papillitis

o SPLINTER HAEMORRHAGES: seen in primary open angle glaucoma, papilloedemao NEOVASCULARISATION: diabetic retinopathy

o PERIPAPILLARY CRESENT: myopia

MACULAo Situated at posterior pole with its centre (foveolar) about 2 disc diameters

lateral to temporal margin of disco Normal-slightly darker than surrounding retina, its centre imparts a bright

reflex-foveal reflexo Abnormalities-

• MACULAR HOLE• MACULAR HAEMORRHAGE• CHERRY RED SPOTS- Neimann Pick’s disease, Gaucher’s disease,

central retinal artery occlusion• MACULAR OEDEMA- trauma, intraocular operations

• 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

RETINAL BLOOD VESSELSo Normal: arterioles-bright red, veins-purplisho 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)

GENERAL BACKGROUNDo Normal-pinkish redo 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

• MICROANEURYSMS-diabetic retinopathy• NEOVASCULARISATION of retina- diabetic retinopathy, sickle cell

retinopathy• TUMOURS of fundus-retinoblastoma• PERIPHERAL RETINAL DEGENERATION• RETINAL HOLES• PROLIFERATIVE RETINOPATHY• RETINAL DETACHMENT

THANK YOU