MBBS Ophth Lecture

1. Dr.Mohd Najmussadiq Khan

3.  Patient profile :- name, sex, age, occupation,
residence, address
 Complaint: - main complaints pain, lacrimation
decrease, visual acuity
 Present history: - each symptom in details.
 Past history: -medical and surgical history e.g.
DM, HT
 Family history:- of same illness, ocular
diseases(e.g. squint, ptosis, congenital
cataract, corneal dystrophy, refractive errors,
glaucoma) & D.M ,HT , allergy
 Drug history. e. g. steroids, chloroquine,
ethambutol

5.  Central retinal artery occlusion
 Central retinal vein occlusion
 Retinal detachment
 Vitreous haemorrhage
 Spontaneous lens dislocation
 Central serous retinopahty
 Optic neuritis

6.  Acute attack of primary angle closure
glaucoma
 Acute attack of secondary angle closure
glaucoma
 Acute iridocyclitis
 Mechanical,chemical or thermal injury

7.  Senile cataract
 Chronic simple glaucoma(POAG)
 Refractive errors
 Choroiditis
 Corneal degeneration
 Age related macular degeneration
 Chronic toxic amblyopia
 Optic atrophy
 Diabetic or hypertensive retinopathy

8.  Chronic iridocyclitis
 Chronic glaucoma
 Entropion,trichiasis
 Interstitial keratitis
 Orbital cellulitis
 Optic nerve compression
 Temporal arteritis

9.  Vitamin-A deficiency
 Advanced OAG
 Retinitis pigmentosa
 Congenital high myopia
 Peripheral corneal or lenticular opacities
 Portal cirrhosis & Oguchis disease

10.  Congenital deficiency of cones
 Central corneal & lenticular opacities
 Central macular choroiditis
 Macular burn & coloboma of the macula

12.  Presbyopia
 Cycloplegia
 Internal/total ophthalmoplegia

15. primary hyperlacrimation
Reflux hyperlacrimation (v nerve irritation)
 Lid – stye,internal hordeolum,acute
meibomitis,trichiasis,concretions,entropion
 Conjunctiva-conjuctivitis
 Cornea-abrasions,ulcers,nonulcerative keratitis
 Sclera-episcleritis,scleritis
 Uveal tissue-iritis, cyclitis,iridocyclitis
 Acute glaucoma
 Endophthalmitis,panophthalamitis
 Orbital cellulitis
Central lacrimation-emotional,hysterical

16. lacrimal pump failure
eversion of lower punctum
 Old age,chronic conjuctivitis,chronic blepharitis,ectropion
punctal obstruction by
 Congenital.injury,burn,foreign
body,concretion,cilia,pilocarpine,idoxuridine
canalicular obstruction by
 Foreign body,trauma,stricture,canaliculitis
lacrimal sac
 Congenital mucous membrane fold
 Traumatic stricture,dacryocystitis
 Tuberculosis,syphilis
 Dacryolithiasis,tumours of sac
 Atonia of the sac
in nasolacrimal duct
 Non canalisation,strictures,inflammation,tumours,
 Surrounding bony disease

17.  CONJUNCTIVITIS,KERATITIS,SCLERITIS,EPISCLE
RITIS, IRIDOCYCLITIS,ACUTE GLAUCOMA
Pain & discharge
General & systemic examination if needed

18. Visual acuity (distant &near)

20. Visual acuity
charts

22. Ishihara colour
plates:
 Right: with a
green filter.
 Left: without the
green filter.

26. Kinetic
visual field
testing with
Goldmann
perimeter

31.  The head is turned in the direction of action
of the paralysed muscle to avoid diplopia
 In ptosis the chin is elevated to uncover
pupillary area

33.  Increased wrinkling due to frontalis
contraction in ptosis
 Absent wrinkling in one half of fore head in
LMN facial falsy

34.  Elevated in ptosis
 Lateral 1/3 shows madrosis in leprosy &
myxedema

35.  Proptosis/exophthalmos-axial or
eccentric,reducible or non reducible ,
pulsatile or non pulsatile
 Enophthalmos
 Visual axis of eye balls(squint)
 Size of eye balls increased in
buphthalmos,myopia and decreased in
microphthalmos,pthisis bulbi,atrophic bulbi

39.  shape -
 position-upper lid covers 2 mm of cornea &
lower lid just touches the cornea.
 In ptosis upper lid covers more than 2 mm and in
lid retraction the upper limbus is visible
 Motility-normal blinking 12-16/min
 Decreased in v nerve anaesthesia,increased in
irritation,absent in 7th nerve palsy
 Lagophthalmos in facial nerve palsy
,proptosis,symblepharon
 lid retraction, swelling ,edema ,pigmentation.

41. Lid edema and redness

42.  Anterior border (round)
 Inter marginal strip having cilia(ant),grey
line(central), meibomian opening(post)
 Posterior border (sharp)
 Entropion and its grading
 Ectropion and its grading
 Swelling at lid margin-inflammation, masses,
stye, papilloma, marginal chalazion

46.  triciasis(misdirected)-
trachoma,stye,blepharitis,trauma
 Distichiasis (extra row)
 madrosis(loss of cilia)-chronic
blepharitis,leprosy,myxedema
 poliosis(greying of cilia)-old age,Vogt-
Koyanagi-Hardas disease
 scales at lid margin-blepharitis

49.  Ankyloblepharon(horizontally narrow) in
ulcerative blepharitis,burns
 Blepharophimosis(all arround narrow)
 Vertical narrow-
blepharospasm,ptosis,enophthalmos,anophth
almos,microphthalmos,phthisis bulbi,atrophic
bulbi
 Vertical wide-proptosis , large eye ball,upper
lid retraction,facial nerve palsy

50.  inspection , palpation examined by pulling up
the outer part of the upper lid while asking
the patient to look downwards and
inwards[note swelling or mass].
 Do regurgitation test with pressure on
lacrimal sac with eyes of the examiner on
puncti.

53. both bulbar and palpebral are examined.

54.  Palpebral conjunctiva of lower lid:- is examined
by pulling the lower lid down while asking the
patient to look upwards .
 Palpebral conjunctiva of upper lid:- is examined
by asking the patient to look downward s then
place the thumb and index finger on upper lid
pull out and down –slightly then press on the lid
which a thin stick ---- exposed surface ,exam.
For dryness ,defects , discharge, follicles ,
papillae .
 Bulbar conjunctiva :- paleness , injection ,
discharge , edema , color .

55.  Color -normally pink in color
 Brownish -melanosis & argyrosis
 pale -anaemia
 bluish -cyanosis
 bright red –subconjuctival haemorrhage
 greyish -muscara

57. Conjuctival (supeficial) Ciliary(deep)
 More in fornices More around limbus
 Bright red Dull red /purple
 Superficial & branching Vessels deep & radial
 Vessels move with conj. Vessels not move
 Vessels fill from fornices Fill from limbus
 Blanching with adrenaline No blanching
 Acute conjuctivitis Acute iridocyclitis,keratitis

59. Ciliary congestion

60.  Conjuctival edema(chemosis)
 Conjuctival follicles—greyish white
aggregation of lymphocytes on the fornix and
palpebral conjuctiva.found in trachoma,acute
or chronic follicular cojuctivitis,benign
folliculosis.
 Cojuctival papillae—reddish areas of vascular
and epithelial hyperplasia.found in
trachoma,spring catarrh,allergic
conjuctivitis,giant papillary conjuctivitis

64.  Concretions—yellowish white hard looking
raised areas.trachoma,cojuctival
degeneration,idiopathic
 Conjuctival foreign body
 Conjuctival scarring—
trachoma,membranous/pseudomembranous
conjuctivitis,healed traumatic wound,operated
scar
 Pinguiculla & pterygium
 Conjuctival cysts—
retention,implantation,lymphatic,cysticercosis
 Conjuctival tumours—
dermoid,papilloma,squamous cell carcinoma

67. Entropion and conjunctival scarring

68. Sub conjunctival haemorrhage

69. Color
 white but yellow in jaundice,
 blue in child,high myopia,scleritis,marfans
synd,pseudoxanthoma elasticum,osteitis
deformans
 pigmentation in melanosis,naevus of ota
Inflammation –scleritis,episcleritis
Staphyloma-thinned out buldging areas of
sclera lined by uveal tissue.
Traumatic perforation

71. Size—diameter 11.7mmvertically and 12.6mm
horizontally.
 microcornea <9mm(microphthalmos,phthisis
bulbi)
 megalocornea >13mm(congenital
megalocornea,buphthalmos)
Shape—like a watch glass but abnormal in
keratoconus,keratoglobus,cornea plana
Surface—irregular surface in ulcer,abrasion
Transparency—absent in edema
,opacity,ulcer,degeneration,dystrophy,deposites,v
ascularisation

73. The
keratometer

74.  Corneal vessels
traced over the
limbus into
conjuctiva
 Brihgt red and well
defined
 Arborescent
branching present
 Epithelium raised
 Corneal surface
irregular
 Corneal vessels
abruptly end at
limbus
 Dull red and ill
defined
 Run parallel to each
other
 Not raised
 Corneal surface
regular

76. Sensitivity—reduced in herpetic
keratitis,neuroparalytic keratitis,leprosy,absolute
glaucoma.It is checked by a thin cotton wool
touching cornea -----reflex lid closure .
Sheen—lost in dry eye
Ulcer—size,site,shape,depth,floor,edges,stain
Opacity—
number,site,size,shape,density[nebular,macular,l
eucomatous]
Back of cornea—Kps
Spetacular bimicroscopy— .

79. Rose Bengal staining of corneal ulcer

86.  Shallow A/C—PACG,extreme young and old
age,hypermetropia,iris bombe,perforating
corneal ulcer/injury,post operative,malignant
gluacoma,anterior lens
subluxation,intumescent cataract,pupllary
block
 Deep A/C—
aphakia,myopia,keratoglobus,keratoconus,bu
phthalmos,total posterior synechiae,lens
dislocation into A/C,posterior globe
perforation,partially absorbed traumatic lens

87.  Irregular A/C—adherent leucoma,iris bombe due to
annular synechiae,tilting of lens
 Blood in A/C[hyphaema]—trauma,surgery,herpes
zooster,gonococcal iridocyclitis
 Pus in A/C[hypopyon]—corneal
ulcer,iridocyclitis,endophthalmitis,panophthalmitis
 Aqueous flare in A/C[inflammatory cells+protein]
 Pseudohypopyon[collection of tumour cells in A/C]—
retinoblastoma,malignant melanoma
 Foreign body in A/C
 Lens particle in A/C after surgery
 Paracytic cyst in A/C—cysticercus
 Artificial lens in A/C

93. Color- between two eyes , appearance of anterior surface.Blue
green in caucacians,dark brown in orientals
 Congenital heterochromia iridium-different colour of two eye
 Hetrochromia iridis-different colour sectors of the same iris
 Greyish atrophic patches in healed iridocyclitis
 Dark pigmented spots in naevi
Iris pattern—normal patter due to collarette,crypts,and radial
striationsin its anterior surface.
 Muddy iris in acute iridocyclitis
 Atrophy of iris in haeled iridocyclitis
Persistent pupillary membrane(PPM)—abnormal congenital tags
Any defect as iridectomy , iridodialysis (lost in inflammation ,
glaucoma .
Congenital defect:- as coloboma aniridia .

95.  Adhesion to cornea k/a posterior or to lens k/a anterior
synechiae.The posterior synechiae may be
annular,segmental,total
 Iris support (normally to lens) if lost k/a iridodonesis or
tremulous iris in aphakia,subluxation.
 New vessels (Rubeosis iridis)—D.M.,CRVO,chronic
iridocyclitis
 Hole in iris—congenital coloboma,surgical iridectomy,laser
iridotomy
 Nodule on iris surface—granulomatous
uveitis,melanoma,tuberculoma,gumma of iris
 Iridodialysis—separation of iris from ciliary body
 Aniridia-congenital absence of iris
 Iridraemia
 Iris cyst

96. Posterior synechiae and pigmentation on anterior lens capsule

101.  normal one in number,polycoria(more than
one),central in location slightly nasal if
eccentric k/a corectopia
 Size -3-4mm

102. MIOSIS
 parasympathomimetcs
 Systemic morphine
 Iridocyclitis,horner
syndrome,head injury,
pontine haemorrhage
 Senile pupil,strong
light,during sleep

MYDRIASIS
 Sympathomimetics like
adrenaline,phenylephrine
 Parasympatholytics like
atropine
,homatropine,tropicamide,c
yclopentolate
 Acute glaucoma,absolute
glaucoma,optic
atrophy,retinal detachment
 Internal
ophthalmoplegia,3rd nerve
paralysis,bellodona
poisoning

103. Shape—circular normally but
 Irregular narrow –iridocyclitis
 Fastooned pupil[patchy dialatation] due to mydriasis in
presence of segmental posterior synechiae
 Vertically oval/updrawn post operatively due to vitreous or
iris incarceration in the wound
color – greyish black normally jet black in aphakia
 greyish white in IMSC pearly white in MSC
 milky white in HMSC
 brown in cataract brunescence
 black in cataract nigra
 yellowish white in retinoblatoma,pseudoglioma
 dirty white in occlusio pupillae,iridocyclitis
 greenish hue in some patients of glaucoma

104.  Reaction to light direct & consensual light
response (light directed into pupil of one eye
constricts both pupils ).
 Marcus-gunn pupil(RAPD)
 Effect of accommodation (for near objects)
 Unequal pupils (Anisocoria) may be normal
unless one or both pupils don’t react well to
light.

105.  movements, cover test---see ocular motility
 Position of the eyes (size , prominence ,
position ).

106. Position—present behind the iris in the patellar
fossa.
 Aphakia—the crystelline lens is absent
 Anterior dislocation of lens into A/C
 Posterior dislocation of lens into vitreous cavity
Subluxation of lens—in this unilateral diplopia is
present due to half pupil phakic and half
pupil aphakic.
 Trauma. Marfan syndrome
 Homocysteinuria. Weillmarchesani syndrome
Shape of the lens—it is biconvex normally but
sometime may be
spherophakia,lenticonus,coloboma of lens

107. Color of lens—in young it is almost clear but in old age even a clear
lens gives greyish hue due to marked scattering of the light as a
result of increased of the refractive index of the lens with
advancing age which is usually mistaken for the cataract.
 Nuclear Cataract-Brown Black
 IMSC-GREYISH WHITE
 MSC—PEARLY WHITE
 HMSC-MILKY WHITE
Transparency—the normal lens is transparent and any opacity in
the lens is called cataract which greyish or yellowish white on
focal illumination. On distant direct ophthalmoscopy the
lenticular opacity appears black against a red fundal glow.
True diabetic cataract-snow flake type
Wilsons disease-sunflower cataract
Concussion injury-rosette cataract

110. Deposites on anterior lens surface—
 Vossius ring—after blunt trauma
 Pigmented clumps—in iridocyclitis
 Dirty white—endophthalmitis,panophthalmitis
 Ferrous iron—siderosis bulbi
 Copper ions—chalcosis
Purkinjes image-
 I—by anterior corneal surface
 II—by posterior corneal surface
 III—by anterior lens surface,absent in aphakia
 IV—by posterior lens surface,absent in aphakia &
MSC

111.  Sclera is palpated with two fore fingers
through the upper lid which patient looking
downwards ,the degree of the fluctuation
gives an indication of ocular tension .normal
range is 15-20mmhg
 More accurate measures are mode by Schiotz
Tonometry.

112. Measurement
of intraocular
pressure using
Goldmann
applanation
tonometer

113.  To see retina and associated structures with
the use of an ophthalmoscope.
 Opacities in media of the eye will appear as
black specks or lines against the red reflex of
the Fundus .
 It can be done with direct /indirect
ophthalmoscopy or slit lamp bimicroscopy.

119.  Top: fundus
examination
with Goldmann
3 mirror
contact lens
 Bottom: fundus
examination
with Hruby non
contact lens

120.  Examine the optic disc ;- shape ----round or
slightly oval . Color -
---- pink, paler than the surrounding
Fundus .
 Physiological cup ------its a depression in
the center of optic disc its paler then the
surrounding and from it the retina vessels
enter and leave the eye .
 Edge of the disc ---- well defined normally
,sometimes there is white scleral ring of dark
pigmented ring surrounding the optic disc.

121.  Examine the retinal vessels :- these radiate from
the disc into many branches as they pass towards
peripheral of retina .Retinal artery is narrower
than veins and brighter red .
 Examine the macular region :- situated 1.5 mm
disc diameters from the temporal border of optic
disc .Its recognized by be darker then
surrounding Fundus no blood vessels .A
depression is present at the center of macular
region (called Fovea ).
 Periphery of Fundus :- its examined only if pupil
is dilated with mydriatic.

124.  Duration :- is visual acuity the as has been ? was change recently ? has
there been gradual diminution of acuity ?.
 Differences in visual acuity in two eyes :- is patient certain that is visual
acuity was same in both eyes.
 Disturbance of vision:- disturbance of the shape of objects
 metamorphopsia mostly due to astigmatism or maular lesions .
 photophobia due to corneal inflammation aphakia, iritis , ocular
albinism.
 Color change( chromatopsia) due to lenticular changes or chorioretinal
lesions , jaundice .
 Halos or rings in glaucoma , cataract
 Spots as dots of filaments moving with the eye.
 Visual field defects by disorders of lids, media ,retina, optic nerve, brain
 night blindness or difficulty seeing in the dark may be congenital e.g
retinitis pigmentosa . or acquired e.g vit A deficiency , glaucoma ….
 Momentary loss of vision (Amaurosis fngax) by cerebrovascular accident
spasm of central retinal artery .

125.  usual painful symptoms mentioned are headache
, eye ache , burning or itching of eyes or eyelids.
 Acute localized pain increased by eye movement
suggest foreign body or corneal abrasion .
 Eye ache often accompanies extreme fatigue
more common in patients with muscle
imbalances also present in inflammation lesion of
iris or choroids , glaucoma , neuralgia….
 Burning and itching ;- eye strain inflammation of
lids or conjunctiva (chronic blepharitis,
conjunctivitis ,Ocular allergy ).
 Pull sensation in case of new lens prescription .

126.  Discoloration :- redness ----- trauma , inflammation ,
allergy , acute glaucoma .
 change color of cornea by corneal ulcer or intraocular
infection .
 yellow sclera seen in jaundice or antimalarial drug toxicity
 blue sclera seen in asteogenic imperfect .
 Swelling :- unilateral swelling of lid ----- local abscess .
 bilateral --------- blepharitis ,allergy ,
myxoedema
 mass:- orbital mass may cause displacement of the
globe.
 Displacement :- eye may be displaced forward of other
directions.Lids may drop(ptosis ) or elevated (retraction ).

127.  diplopia double vision one object seen as
two
 time of onset .
 constant or intermittent .
 whether the two objects are horizontal or
vertical .
 vertigo sensation of irregular or whirling
motion either of oneself or external objects
.attacks are frequently associated with
sudden changes in position or posture of
head and neck.

128.  type and amount of discharge .
 if discharge is watery [epiphora ] are not
associated with pain or redness ------
excess tear formation or obstruction of
Lacrimal system .
 if epiphora with photophobia or burning ----
---viral conjunctivitis or keratoconjunctivitis .
 purulent discharge------ bacterial infection .

129.  Many systemic disorders have decrease tear .
 Dryness of eye is frequent in elderly and
some collagen disorder e.g sjogren syndrome
 Excessive tearing may be due to allergy ,
acute inflammation , disease of eye , chemical
irritation or tear duct obstruction .