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Nursing assessment of eye part1

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Nursing assessment of eye part1

  1. 1. Nursing Assessment of eye Gauri S. Shrestha, M.Optom, FIACLE Part I
  2. 2. Learning Objective <ul><li>Able to describe importance of history taking </li></ul><ul><li>Able to describe distant visual acuity </li></ul><ul><li>Able to describe eye alignment test </li></ul><ul><li>Able to describe eye movement </li></ul><ul><li>Able to describe pupillary reaction </li></ul><ul><li>Able to describe anterior segment examination of eye </li></ul><ul><li>Able to describe posterior segment of the eye </li></ul>
  3. 3. Patient History <ul><li>Helps acquire a skill necessary to perform an examination </li></ul><ul><li>The first and the most important aspects that informs us why the patient sought the nursing care </li></ul>
  4. 4. Purpose <ul><li>To acquire a skill necessary to perform an examination. </li></ul><ul><li>To acquire base line information for the examination. </li></ul><ul><li>To guide the patients with questions those are most productive and extract relevant information. </li></ul><ul><li>To determine which specific tests or procedures should be performed during the examination ultimately leading to definitive diagnosis and management plan. </li></ul>
  5. 5. Patient preparation <ul><li>Greet the patient and be polite. </li></ul><ul><li>Establish an interpersonal relation to build confidence of patient. </li></ul><ul><li>Make patient comfortable sitting arrangement in the room such as arrange comfortable stool, adjusting room temperature, provide a glass of water etc </li></ul>
  6. 6. Implementation <ul><li>DEMOGRAPHIC DATA </li></ul><ul><ul><li>In includes patient's full name, birth date, gender, complete address, contact telephone number and occupation. </li></ul></ul><ul><li>GENERAL OBSERVATION </li></ul><ul><ul><li>treat as a person </li></ul></ul><ul><ul><li>remain aware of all aspects of the patient's personal as well as visual and ocular needs. </li></ul></ul><ul><ul><li>Observation </li></ul></ul><ul><ul><li>Note how patient walks, his stature, gait, head position, facial asymmetry, skin color, speech, and odor. </li></ul></ul>
  7. 7. Implementation CASE HISTORY <ul><li>Patient's chief complaint </li></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><li>Distance or near blur vision, double vision, eye strain, watering, burning, stinging, redness, swelling, floater, ocular injury. </li></ul></ul><ul><ul><li>Routine examination. </li></ul></ul><ul><ul><li>The referred cases of headache, diabetes mellitus, hypertension, tuberculosis. </li></ul></ul><ul><ul><li>Hysterical vision loss. </li></ul></ul>
  8. 8. Implementation VISUAL AND OCULAR HISTORY <ul><li>It tells the importance of eye care. </li></ul><ul><li>seeking another opinion. </li></ul><ul><li>provides a record of changes that may have occurred over time. eg. recurrent uveitis, myopia progression. </li></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><li>Duration of complaint, history of recurrence, associated other ocular symptoms, progression of diseases, duration of treatment received, history of injuries or surgeries, last eye examination. </li></ul></ul>
  9. 9. Implementation MEDICAL HISTORY <ul><li>rule out ocular manifestation of systemic conditions. </li></ul><ul><li>reveals such pertinent systemic condition which patients find not important. </li></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><li>History of hypertension, Diabetes mellitus, Thyroid diseases, or arthritis, multiple sclerosis, arteritis, asthma etc, </li></ul></ul>
  10. 10. Implementation MEDICATION AND HYPERSENSITIVITY <ul><li>History of medications helps to elicit visual as well as ocular manifestation of medications of systemic medicines . </li></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><li>History of any systemic medications causing ocular manifestations </li></ul></ul><ul><ul><ul><li>Antianxiety (diazepam) agents, B-blockers, and antihistamines causes decrease aqueous tear secretion leading to dryness. </li></ul></ul></ul><ul><ul><ul><li>Chloroquine - retinal pigment epithelial changes, Visual Field defect, and Color vision defect. </li></ul></ul></ul><ul><ul><ul><li>Ethanbutol intake - retrobulbar optic neuritis. </li></ul></ul></ul><ul><ul><ul><li>Steroids - glaucoma; delay wound healing, and posterior capsular cataract </li></ul></ul></ul><ul><ul><li>History of ocular medication which can cause systemic manifestation </li></ul></ul><ul><ul><ul><li>Cycloplegics can cause hallucination, dry mucosa, and fever. </li></ul></ul></ul>
  11. 11. Implementation FAMILY OCULAR HISTORY <ul><li>A history of poor vision in the family- definitive link to an accurate diagnosis. </li></ul><ul><li>Hereditary- a powerful tool in making the correct diagnosis. </li></ul><ul><li>Assessment </li></ul><ul><ul><li>History of the similar diseases in family. All of corneal, vitreal, retinal, choroidal dystrophies are hereditary. </li></ul></ul><ul><ul><li>History of similar type of vision loss or any inflammation particularly in first degree relatives (parents). e.g., glaucoma, strabismus, amblyopia or myopia. </li></ul></ul><ul><ul><li>History of the similar episodes in many family members in subsequent generation or in specific gender </li></ul></ul><ul><ul><li>Autosomal dominant trait is mostly found in aniridia, congenital cataract, retinoblastoma, cone dystrophy. </li></ul></ul><ul><ul><li>Autosomal recessive in retinitis pigmentosa. </li></ul></ul><ul><ul><li>X-linked in ocular albinism, and red-green color deficiency. </li></ul></ul>
  12. 12. Implementation FAMILY MEDICAL HISTORY <ul><li>Similarly, it is important to know diseases that may exist in other family members. </li></ul><ul><li>Assessment </li></ul><ul><ul><li>History of the similar pattern of diseases in cousins, nephews, uncles and aunt etc., </li></ul></ul><ul><ul><li>Some diseases such as diabetes may have chances of genetic predisposition where as hypertension and multiple sclerosis may have high frequency in family members yet not be inherited in a known pattern. </li></ul></ul>
  13. 13. Implementation VOCATIONAL AND RECREATIONAL DEMAND <ul><li>Consideration of the vocational needs of patient </li></ul><ul><li>ask about the special visual need of the patient. </li></ul><ul><li>Assessment </li></ul><ul><ul><li>Special demands for visual acuity, potential for eye injury, or use of protective devices. </li></ul></ul>
  14. 14. Summary <ul><li>Upon complete history taking, nurse will be able to develop individualized goals for examination and assessment, identify presence of abnormality, and make patient aware of signs and symptom of eye diseases. History taking helps to gain patient’s confidence, also prepares the patient for further assessment and examination procedure </li></ul>
  15. 15. Visual acuity <ul><li>Visual acuity is the resolving power of the eye </li></ul><ul><li>Measures a quality & ability of the eye to resolve varying letter sizes </li></ul><ul><li>In 1862, Snellen introduced a system for measuring visual acuity, is still the fundamental tool </li></ul><ul><li>Measured conventionally at 6m (20ft) distance for distant vision </li></ul>Snellen Fraction = Testing Distance Designation of smallest line read
  16. 16. Visual acuity <ul><li>Snellen acuity is based on a minimum angle of resolution of 1 min of arc </li></ul>Testing distance of 6 m θ MAR
  17. 17. Visual acuity <ul><li>Purpose </li></ul><ul><ul><li>To quantify visual acuity. </li></ul></ul><ul><ul><li>To determine severity of vision impairing disorders. </li></ul></ul><ul><ul><li>To classify visual impairment, low vision and blindness </li></ul></ul><ul><li>Assessment of patient </li></ul><ul><ul><li>Assess vision related history such type of vision loss (gradual, sudden, transient) as time of onset, duration, history of spectacle wear. </li></ul></ul><ul><ul><li>Assess history of red eye, pain, swelling, diplopia, photophobia, trauma, surgery. </li></ul></ul><ul><ul><li>Observe abnormality in posture, capacity to comprehension. </li></ul></ul>
  18. 18. Visual acuity <ul><li>Required Instrument </li></ul><ul><ul><li>Snellen vision chart </li></ul></ul><ul><ul><li>Occluder </li></ul></ul><ul><ul><li>Patient's habitual glasses (if present) </li></ul></ul><ul><ul><li>Pin hole </li></ul></ul><ul><li>Patient preparation </li></ul><ul><ul><li>Position patient at the appropriate distance i.e. 6 meter from the vision chart in adequately illuminated room. </li></ul></ul><ul><ul><li>Explain patient about the nature and importance of the test to seek his or her confidence. </li></ul></ul>
  19. 20. Distant Visual Acuity Depending upon the distance at which top letter can be read, vision is recorded as 5/60, 3/60, 1/60 Below 1m distance, CF 3ft, CF 2ft, CF 1ft, CFCF HM ± , PR ±, PL +, NPL Able to read up to 36m line= 6/36 Able to read up to 60m line= 6/60 Able to read up to 6m line= 6/6
  20. 21. Evaluation <ul><li>Record the score of Snellen test as visual acuity unaided, with correction, and pin hole. </li></ul><ul><li>Visual acuity of 6/6 is considered normal and visual acuity of less than 6/6 is clinically considered abnormal. </li></ul><ul><li>Functionally, visual acuity less than 6/12 is considered abnormal. </li></ul>
  21. 22. EYE ALIGNMENT TEST <ul><li>Introduction </li></ul><ul><li>Proper eye alignment is necessary for clear, comfortable, binocular vision. Poor eye alignment can lead to eyestrain, blurred vision, double vision, strabismus, and amblyopia. </li></ul><ul><li>Purpose </li></ul><ul><ul><li>To determine the presence or the absence of deviation in eye. </li></ul></ul><ul><ul><li>To detect latent nystagmus. </li></ul></ul><ul><ul><li>To detect fixation preference in infants and toddlers. </li></ul></ul>
  22. 23. <ul><li>Assessment of patient </li></ul><ul><ul><li>Assess history of eyestrain, headache, double vision </li></ul></ul><ul><ul><li>Assess family history of squint and amblyopia. </li></ul></ul><ul><ul><li>Assess history of eye and head injury. </li></ul></ul><ul><ul><li>Notice abnormal head adaptations such as head tilt and face turn. </li></ul></ul><ul><li>Required Instrument </li></ul><ul><ul><li>Occluder </li></ul></ul><ul><ul><li>Pen torch light </li></ul></ul><ul><ul><li>Fixation target </li></ul></ul><ul><li>Patient preparation </li></ul><ul><ul><li>Explain patient about the nature of the test to seek his or her confidence and co-operation. </li></ul></ul><ul><ul><li>Seat patient comfortably in dimly illuminated room. </li></ul></ul>
  23. 24. Procedure <ul><li>Comfortable sitting arrangement </li></ul><ul><li>Dim room light. </li></ul><ul><li>Flash a penlight onto the bridge of the patient's nose from 40-50cm away. </li></ul><ul><li>Look for the spot on both corneas where the light shines. </li></ul><ul><li>Light shines symmetrically at equal distance at the pupillary center </li></ul>
  24. 25. Cover test
  25. 26. Cover test
  26. 27. Cover test
  27. 28. Cover test   
  28. 29. Cover Test  
  29. 30. Left eye exotropia
  30. 31. Exophoria
  31. 33. Evaluation <ul><li>Symmetry in corneal light reflex in two eyes generally indicates that there is no deviation. </li></ul><ul><li>Asymmetry in corneal light reflex suggests that there is a squint. </li></ul>
  32. 34. Strabismus <ul><li>Ocular misalignment </li></ul><ul><li>Strabismus present or absent </li></ul><ul><ul><li>Inward (esotropia) </li></ul></ul><ul><ul><li>Outward (exotropia) </li></ul></ul><ul><ul><li>Upward (hypertropia) </li></ul></ul><ul><ul><li>Downward (hypotropia) </li></ul></ul><ul><ul><li>Rotation in (encyclotropia) </li></ul></ul><ul><ul><li>Rotation out (excyclotropia) </li></ul></ul><ul><ul><li>combination </li></ul></ul>
  33. 35. EXTRAOCULAR MUSCLE MOVEMENT <ul><li>Introduction </li></ul><ul><li>Extraocular muscle movement is tested in different gazes to investigate their integrity and integrity of their associated nerves. </li></ul><ul><li>Defect in ocular motor systems may result from muscular as well as neurological causes. </li></ul><ul><li>Purpose </li></ul><ul><ul><li>To investigate integrity of extraocular muscles. </li></ul></ul><ul><ul><li>To investigate integrity of associated nerves of extraocular muscles. </li></ul></ul><ul><ul><li>To measure extent of the movement of extraocular muscles. </li></ul></ul>
  34. 36. <ul><li>Assessment of patient </li></ul><ul><ul><li>Assess history of trauma to eye, diplopia, headache associated with nausea and vomiting, scotoma at the fixation, and scintillation. </li></ul></ul><ul><ul><li>Notice any abnormal head posture such head tilt right or left, chin up or down, face turn to left or right, and dropping of eye lids. </li></ul></ul><ul><ul><li>Notice patient feeling pain on movement of eyeball. </li></ul></ul><ul><ul><li>Assess best corrected or pin hole visual acuity to notice decrease in visual acuity. </li></ul></ul><ul><li>Required Instruments </li></ul><ul><ul><li>A pen light or transilluminator </li></ul></ul><ul><ul><li>Fixation target </li></ul></ul>
  35. 37. <ul><li>Patient preparation </li></ul><ul><ul><li>If the patient wears spectacle or contact lenses, make sure their removal. </li></ul></ul><ul><ul><li>Explain patient about the nature of the test to seek his or her confidence and co-operation. </li></ul></ul><ul><ul><li>Seat patient comfortably in adequately illuminated room. </li></ul></ul>
  36. 38. DIAGNOSTIC POSITIONS OF GAZE
  37. 39. Ocular motility test RSR RLR RIR RSO MR RIO LIO LSR LLR LIR LSO
  38. 41. Evaluation <ul><li>The key observations to note are overaction or restriction in specific gaze. </li></ul><ul><li>Recorded on basically six gazes: Right, right up, right down, left, left up, and left down. </li></ul>
  39. 42. TESTS OF PUPILLARY FUNCTION <ul><li>Introduction </li></ul><ul><li>Testing a patient's pupillary function involves </li></ul><ul><ul><li>measurement of pupil size and measurement of light reflexes. </li></ul></ul><ul><li>Purpose </li></ul><ul><ul><li>To measure and compare size of the pupil for detecting anisocoria (unequal pupil size). </li></ul></ul><ul><ul><li>To measure and compare shape of the pupil related to trauma, surgery, and/ or inflammation of the eye. </li></ul></ul><ul><ul><li>To assess pupil's reaction to light for detecting abnormality in function of iris, optic nerve, and visual pathway. </li></ul></ul>
  40. 43. <ul><li>Assessment of patient </li></ul><ul><ul><li>Same as extraocular movement assessment. </li></ul></ul><ul><li>Required Instruments </li></ul><ul><ul><li>A pen light or transilluminator </li></ul></ul><ul><ul><li>Millimeter ruler </li></ul></ul><ul><ul><li>A fixation target </li></ul></ul><ul><li>Patient preparation </li></ul><ul><ul><li>If the patient wears spectacle or contact lenses, make sure their removal. </li></ul></ul><ul><ul><li>Explain patient about the nature of the test to seek his or her confidence and co-operation. </li></ul></ul><ul><ul><li>Seat patient comfortably in dimly illuminated room. </li></ul></ul>
  41. 44. PUPIL SIZE MEASUREMENT <ul><li>Have a patient fixate a distance target in a room illuminated enough to see the pupil. </li></ul><ul><li>Place the ruler by nurse's non-dominant hand on measuring eye on the supraorbital ridge and position it so that half of the pupil is covered. </li></ul><ul><li>Measure and record the size of the pupil of each eye with the help of millimeter ruler. Record the </li></ul>
  42. 45. Pupillary reaction <ul><li>Direct and consensual </li></ul>Whenever pupil is shine with light should constrict. Absence of constriction indicates the presence of abnormality. When direct and indirect pupillary response is absent, indicate that direct pupillary light response is negative.
  43. 46. Pupillary reaction <ul><li>Swinging flash light </li></ul>
  44. 47. Pupillary reaction <ul><li>Swinging flash light </li></ul>If the rate of constriction of pupil is the same in each eye when the light is shine in the eye, the result should be recorded as negative. This is the normal response. If the rate of constriction of the two pupils is different, or the pupil of the eye receiving the light dilates instead of constriction, the results are recorded as a positive response. This is abnormal finding. It is recorded as RAPD (relative afferent pupillary defect) positive or negative.
  45. 48. ASSESS EXTERNAL (ANTERIOR) EYE STRUCTURES <ul><li>Introduction </li></ul><ul><li>The external examination includes a gross inspection of the external structures of the eye by means of magnifying loupe and slit lamp biomicroscopy. </li></ul><ul><li>Purpose </li></ul><ul><ul><li>To examine anterior eye structure in routine. </li></ul></ul><ul><ul><li>To detect any abnormality such as infection, inflammation, swelling, opacity in anterior eye structures. </li></ul></ul><ul><ul><li>To detect diseases of lids, conjunctiva, sclera, episclera, cornea, and lens. </li></ul></ul><ul><ul><li>To assess anterior chamber angle depth. </li></ul></ul>
  46. 49. ASSESS EXTERNAL (ANTERIOR) EYE STRUCTURES <ul><li>Assessment of patient </li></ul><ul><li>Assessment includes brief history related to eye and systemic health. Problem identified during history and the preliminary eye examination should be further evaluated. </li></ul><ul><li>Assess history of trauma or swelling of eye and adnexa. </li></ul><ul><li>Preliminary eye examination should include, ectropion, intropion, pupillary reaction, redness, swelling of anterior segment of eye, watering, color of conjunctiva, color of cornea (transparent). </li></ul><ul><li>Assess visual acuity unaided, with glasses and pin hole. </li></ul>
  47. 50. ASSESS EXTERNAL (ANTERIOR) EYE STRUCTURES <ul><li>Instrumentation </li></ul><ul><li>Magnifying loupe. </li></ul><ul><li>Slit lamp biomicroscope </li></ul><ul><li>Patient preparation </li></ul><ul><li>If the patient wears spectacle or contact lenses, make sure their removal. </li></ul><ul><li>Explain patient about the nature of the test to seek his or her confidence and co-operation. </li></ul><ul><li>Seat patient comfortably in dimly illuminated room in front of slit lamp. </li></ul><ul><li>Set the goal of anterior eye examination. </li></ul>
  48. 51. Slit lamp examination <ul><li>Invaluable and indispensable part of ophthalmological examination </li></ul><ul><li>Parts </li></ul><ul><ul><li>Observation system (Microscope) </li></ul></ul><ul><ul><li>Illumination system (Slit lamp) </li></ul></ul><ul><li>Use, </li></ul><ul><li>examination of detailed structure of eye </li></ul><ul><li>Measurement of corneal thickness, anterior chamber depth </li></ul><ul><li>Visiometry </li></ul>Gauri S Shrestha, M.Optom
  49. 52. Examination of eye lids and eye brows <ul><li>Inspect the level of two eye brows, symmetry in lid crease eg ptosis </li></ul><ul><li>Inspect eye lashes: </li></ul><ul><ul><li>absent (madarosis) whitening (poliosis) irregular red lid margins (pediculosis) </li></ul></ul><ul><li>Position of eye lids </li></ul><ul><ul><li>Upper eye lid covers 1/6 th of cornea </li></ul></ul><ul><ul><li>Lower eye lids just touches limbus </li></ul></ul><ul><li>Movement: follow the movement of eye ball in down ward gaze (lags behind in graves diseases) </li></ul>
  50. 53. Examination of eye lids <ul><li>Blinking: Inspect whether normal blinking present </li></ul><ul><ul><li>Excessive blinking : FB in eye, lid irritation, dry eye </li></ul></ul><ul><ul><li>Blinking reduced or absent : trigeminal anesthesia, 7 th nerve praresis </li></ul></ul><ul><ul><li>Lagophthalmos (incomplete closure of eye lids) eg proptosis, congenital ptosis, facial nerve palsy </li></ul></ul><ul><li>Lid margin mark any of the following </li></ul><ul><ul><li>Entropion, ectropion, Trichiasis, districhiasis, madarosis, poliosis, scales </li></ul></ul>LAGOPHTHALMOS
  51. 54. Palpebral aperture <ul><li>It is a exposed space b/w two lid margins </li></ul><ul><ul><li>8-10mm vertical, 25-30mm horizontal </li></ul></ul><ul><ul><li>Ankyloblepharon: horizontal narrow fissure </li></ul></ul><ul><ul><li>Blepharophimosis: narrow fissure all around </li></ul></ul><ul><ul><li>Vertical narrow fissure: ptosis, endophthalmos, microphthalmos, anophthalmos </li></ul></ul><ul><ul><li>Vertical wide fissure: proptosis, retraction of upper lid </li></ul></ul>
  52. 55. Examinations of lacrimal apparatus <ul><li>Examination is important in cases with epiphora in corneal ulcers and before surgery </li></ul><ul><li>Inspect lacrimal puncta for eversion, stenosis, absent, or discharge </li></ul><ul><li>Lacrimal sac area inspection : </li></ul><ul><ul><li>redness, swelling, fistula </li></ul></ul><ul><li>Regurgitation test </li></ul><ul><ul><li>press over the lacrimal sac at medial canthus to inspect regurgitation of discharge from the puncta </li></ul></ul>
  53. 56. Examination of eye ball <ul><li>Inspect symmetry of eye ball </li></ul><ul><ul><li>Bulging of eye ball (expohthlamos/ proptosis) </li></ul></ul><ul><ul><li>Shrunken of eye ball (Endophthalmos) </li></ul></ul>
  54. 57. Examination of conjunctiva <ul><li>It includes </li></ul><ul><ul><li>Bulbar conjunctiva, upper palpebral conjunctiva, lower palpebral conjunctiva, and fornix </li></ul></ul><ul><li>Upper palpebral conjunctiva is examined everting upper lid </li></ul>Upper palpebral conjunctiva examination Lower palpebral conjunctiva examination
  55. 58. Examination of conjunctiva <ul><li>Coloration: </li></ul><ul><ul><li>Semi transparent , brownish, grayish, muddy appearance </li></ul></ul><ul><li>Congestion of vessels : </li></ul><ul><ul><li>superficial, deep </li></ul></ul><ul><ul><li>Circum-corneal, limbal, bulbar, mixed </li></ul></ul>Anterior uveitis Chemosis Concretion
  56. 59. Examination of conjunctiva <ul><li>Conjunctival chemosis (edema), Follicles and papillae, concretion, pinguecula & pterigium </li></ul>Follicles
  57. 60. Examination of sclera <ul><li>Color </li></ul><ul><ul><li>White, yellow, bluish, pigments </li></ul></ul><ul><li>Inflammation, Staphyloma, foreign body entraped (transparent), perforation </li></ul>Yellow sclera Blue sclera Pigments Staphyloma
  58. 61. Cornea <ul><li>Diameter </li></ul><ul><li>Shape : corneal curvature </li></ul><ul><li>Surface : ulceration, abrasion, vascularization, distortion, </li></ul><ul><li>Transparency: </li></ul><ul><ul><li>bright shining, cornea edema, opacity </li></ul></ul>Corneal Ulcer Corneal abrasion Corneal vascularization Corneal distortion Corneal opacity Corneal edema
  59. 62. Cornea <ul><li>Corneal sensation : </li></ul><ul><ul><li>hepetic keratitis, diabetic mellitus, absolute glaucoma, neuroparalytic keratitis </li></ul></ul><ul><li>Keratic precipitate, pigments at back surface of cornea </li></ul>Herpetic keratitis Keratic precipitate
  60. 63. Examination of Anterior chamber <ul><li>Depth </li></ul><ul><ul><li>Shallow, normal, deep </li></ul></ul>Gauri S Shrestha, M.Optom <ul><li>Contents </li></ul><ul><ul><li>Transparent watery fluid, </li></ul></ul><ul><ul><li>presence of any particles is abnormal </li></ul></ul><ul><ul><ul><li>Eg pus (hypopyon) Blood (hyphaema), cells, flares, FBs, </li></ul></ul></ul>
  61. 64. Examination of Iris <ul><li>Color: </li></ul><ul><ul><li>racial variation, white, Heterochromia iridis, darkly pigmented, </li></ul></ul><ul><li>Findings </li></ul><ul><ul><li>Persistent pupillary membrane, </li></ul></ul><ul><ul><li>synachiae. </li></ul></ul><ul><ul><li>Iridodonesis, </li></ul></ul><ul><ul><li>nodules, </li></ul></ul><ul><ul><li>Rubeosis iridis </li></ul></ul><ul><ul><li>Peripheral iridectomy </li></ul></ul><ul><ul><li>Aniridia </li></ul></ul><ul><ul><li>Albinism </li></ul></ul>Gauri S Shrestha, M.Optom Heterochromia iridis Persistent pupillary membrane synachiae Nodules Rubeosis Iridis Peripheral iridectomy Aniridia Albinism
  62. 65. Examination of Pupil <ul><li>Shape: </li></ul><ul><ul><li>circular, irregular </li></ul></ul>Gauri S Shrestha, M.Optom Irregular pupil <ul><li>Color : </li></ul><ul><ul><li>jet black, greyish white, pearly white, milky white, brown, Leucocoria, occluded </li></ul></ul><ul><li>Pupillary reaction: </li></ul><ul><ul><li>Direct, consensual light reflex, swinging flash light test, near reflex </li></ul></ul>Leucocoria
  63. 66. Examination of Pupil <ul><li>Number of pupil ; One or more (polycoria) </li></ul><ul><li>Location centric or eccentric (corectopia) </li></ul><ul><li>Size : normal, miosis, mydriasis </li></ul>Gauri S Shrestha, M.Optom Polycoria Corectopia
  64. 67. Lens <ul><li>Position : </li></ul><ul><li>Abnormality of position may be </li></ul><ul><ul><li>Dislocation of lens </li></ul></ul><ul><ul><li>Subluxation of lens </li></ul></ul><ul><ul><li>Aphakia </li></ul></ul><ul><ul><li>Pseudophakia </li></ul></ul>Gauri S Shrestha, M.Optom
  65. 68. Lens <ul><li>Shape </li></ul><ul><ul><li>biconvex structure </li></ul></ul><ul><li>Abnormal lens shape may be </li></ul><ul><ul><li>Spherophakia </li></ul></ul><ul><ul><li>Lenticonus </li></ul></ul><ul><ul><li>Coloboma of lens </li></ul></ul>Gauri S Shrestha, M.Optom
  66. 69. Lens <ul><li>Color </li></ul><ul><ul><li>Clear or faint blue hue with transparency </li></ul></ul><ul><ul><li>grayish white (immature senile cataract) </li></ul></ul><ul><ul><li>Pearly white to milky white (mature cortical cataract) </li></ul></ul><ul><ul><li>Yellow brown (hypermature) </li></ul></ul>Gauri S Shrestha, M.Optom
  67. 70. Lens <ul><li>Cataract </li></ul><ul><ul><li>Description of cataract with its anatomical position eg anterior cortical, nuclear, polar, lamellar, rosette, snow flake, PSC </li></ul></ul>Gauri S Shrestha, M.Optom
  68. 71. Summary <ul><li>With a practice and experience, slit lamp examination requires only a few minutes of examination time. It will yield invaluable information that will be used to document the health and integrity of the anterior ocular structures. </li></ul>
  69. 72. ASSESSMENT OF INTERNAL EYE STRUCTURE <ul><li>Assessment of internal eye structure includes </li></ul><ul><ul><li>assessment of middle vitreous, </li></ul></ul><ul><ul><li>posterior vitreous, </li></ul></ul><ul><ul><li>fundus (retina) and optic disc. </li></ul></ul><ul><li>Purpose </li></ul><ul><ul><li>To examine internal eye structure in routine. </li></ul></ul><ul><ul><li>To detect any abnormality such as opacity in vitreous. </li></ul></ul><ul><ul><li>To detect any abnormality in retina such as cupping of disc, hemorrhage, exudates, scars, and tear. </li></ul></ul>
  70. 73. <ul><li>Assessment of patient </li></ul><ul><ul><li>Assess history of decrease in vision, sudden loss of vision, diabetes mellitus, hypertension, high myopia, glaucoma, and other systemic conditions. </li></ul></ul><ul><ul><li>Evaluate presence of any media opacities or cataract, squint, ocular movement, and diseases of anterior segments. </li></ul></ul><ul><ul><li>Assess best corrected visual acuity. </li></ul></ul><ul><ul><li>Assess history of trauma or swelling of eye and adnexa. </li></ul></ul><ul><li>Required Instrument </li></ul><ul><ul><li>Monocular direct ophthalmoscope </li></ul></ul><ul><li>Patient preparation </li></ul><ul><ul><li>Explain patient about the nature of the test to seek his or her confidence and co-operation. </li></ul></ul><ul><ul><li>Seat patient comfortably in dimly illuminated room in front nurse. </li></ul></ul><ul><ul><li>Check the purpose of the test. </li></ul></ul><ul><ul><li>Make sure removal of patient's spectacle. </li></ul></ul>
  71. 75. Vitreous examination <ul><li>A transparent and inert cavity </li></ul><ul><li>Look for </li></ul><ul><ul><li>Any cells, opacities, hemorrhage, fibrosis </li></ul></ul>Gauri S Shrestha, M.Optom
  72. 76. Retina <ul><li>Optic disc: </li></ul><ul><ul><li>Size: 1.5mm </li></ul></ul><ul><ul><li>Shape: round or oval </li></ul></ul><ul><ul><li>Margins: well defined </li></ul></ul><ul><ul><li>Color: pinkish with central pallor area (cup) </li></ul></ul><ul><ul><li>Cup disc ratio: less than 0.3 </li></ul></ul>
  73. 77. Retina <ul><li>Abnormal: </li></ul><ul><ul><li>blurred disc margin, </li></ul></ul><ul><ul><li>large cup disc ratio, </li></ul></ul><ul><ul><li>haemorrhage, </li></ul></ul><ul><ul><li>neovascularization, </li></ul></ul><ul><ul><li>myopic crescent </li></ul></ul>Gauri S Shrestha, M.Optom
  74. 78. Retina <ul><li>Macula </li></ul><ul><ul><li>Situated at the posterior pole 2 disc diameter lateral to disc margin </li></ul></ul><ul><ul><li>It is the darkly pigmented area in retina </li></ul></ul><ul><ul><li>Fovea is the vessels free zone visualized as bright reflex </li></ul></ul>Gauri S Shrestha, M.Optom
  75. 79. Retina <ul><li>Examine </li></ul><ul><ul><li>Macular hole, cherry red spot, macular edema, exudates, drusens, scarring </li></ul></ul>Gauri S Shrestha, M.Optom
  76. 80. Retina <ul><li>Retinal blood vessels </li></ul><ul><ul><li>Arterioles are smaller, brighter than vein running parallel </li></ul></ul><ul><ul><li>A:V :: 2:3 </li></ul></ul><ul><li>Examine for </li></ul><ul><ul><li>Narrowing of arterioles, tortuosity of vessels, sheathing, pulsation </li></ul></ul>Gauri S Shrestha, M.Optom
  77. 81. Retina <ul><li>General background </li></ul><ul><ul><li>Pinkish red in color (Physiologic variation possible) </li></ul></ul>Gauri S Shrestha, M.Optom <ul><ul><li>Tessellated and tigroid fundus: </li></ul></ul><ul><ul><li>visibility of choroidal pigments </li></ul></ul>Retinal hemorrhage Exudates Retinitis pigmentosa microaneurisms
  78. 82. Summary <ul><li>List in sequential order of components of history taking. </li></ul><ul><li>Lists the things we observe during history taking and examination. </li></ul><ul><li>How is the visual acuity denoted? </li></ul><ul><li>List the anterior ocular structures under examination </li></ul><ul><li>List the posterior ocular structures under examination. </li></ul>Gauri S Shrestha, M.Optom
  79. 83. Thank you

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