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Examination of Eye

Examination of Anterior Segment


Part - II
Copy of Lecture taken by
Dr Sanjay Shrivastava
Professor of Ophthalmology
for Junior Final year students of
Gandhi Medical College, Bhopal
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Examination of Cornea
Examination of cornea is done under the
following headings
1. Shape
2. Size
3. Surface
4. Transparency
5. Corneal Sensation
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Uniocular Loupe
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Examination of Cornea
Size
Normal Diameter
Horizontal 11 mm
Vertical 10.6 mm
Size Measured by
Transparent rule
Slit Lamp
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Corneal Size
Size Increased
- Megalocornea
- Buphthalmos
- Keratoglobus
Size Decreased :
- Microcornea
- Microphthalmos
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Corneal Shape
Shape of Cornea
Normal cornea is elliptical with regular
curvature.
Examined by help of slit beam on slit lamp.
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Curvature
Flat Cornea :
Cornea plateau
Atrophic bulbi
Conical Cornea :
Keratoconus
Globular Cornea :
Keratoglobus
Anterior staphyloma
Buphthalmos
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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.
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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.
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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.
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Corneal edema in Angle Closure
Glaucoma
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Corneal Ulcer
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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
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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

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Nebulomacular Corneal Opacity
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Leucomatous Corneal Opacity
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Leucomatous Corneal Opacity
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Dry Eye with Corneal Opacity
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Corneal Edema
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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.

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Salzman Nodular Degeneration
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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.
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Superficial Vascularization
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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
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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
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Ciliary Congestion + KPs in a case
of Iridocyclitis
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Slit lamp
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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
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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
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Blue sclera
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Abnormalities of Sclera
1. Nodule
2. Thinning / pigmentation
3. Ectasia
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Episcleritis
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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
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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
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Deep Anterior Chamber
Causes of Deep Anterior Chamber
Infants
High Myopia
Keratoglobus
Keratoconus
Buphthalmos.
Aphakia
Post dislocation of lens
Total post synechia
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Irregular depth of Anterior Chamber
Causes
Subluxation of lens
Iris bombe
Adherent leucoma
Traumatic cataract
Tumor of iris and cilliary body.
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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
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Hypaema
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Hypopyon
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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
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Anatomy of Angle of AC
Sketch by Dr Shikha
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GONIOSCOPIC VIEW
Sketch by Dr Shikha
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Examination of Iris
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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

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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)
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Normal Pattern of Iris
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Note Iris Colour & Pattern
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Healed Iridocyclitis
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Iris Coloboma with Cataract
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Post Laser Iridotomy
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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
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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.
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Iridocyclitis
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Posterior Synechia
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Healed iridocyclitis
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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
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Iridodialysis
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Coloboma of Iris
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Examination of Pupil
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Pupils
Pupil is the circular aperture in the centre
of iris. Its normal size is 3-4mm. it is
grayish black in colour.
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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
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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
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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
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Note Dilated pupil of Left eye
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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)
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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.
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Yellow reflex in pupillary area
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Irregular pupil in a case of iridocyclitis
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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
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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
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EXAMINATION OF LENS
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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

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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
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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.
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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.
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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.
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Congenital Cataract
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Immature Cataract
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Advanced Immature Cataract
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Immature Cataract
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Aphakia
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Traumatic Cataract
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Pseudophakia
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Intumescent Cataract
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PC IOL with Capture
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PC IOL with Capture
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PC IOL
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AC IOL