This document discusses the evaluation of ocular examination in cataract patients. It covers various components of the eye exam including head posture, facial asymmetry, visual axis, ocular movements, eyelids, conjunctiva and more. Abnormal head postures can indicate strabismus while facial asymmetry may be due to dental, skeletal or muscular issues. Tests like cover tests are used to evaluate the visual axis and detect strabismus. Ocular movements involve evaluations of ductions, versions, vergences and following diagnostic positions of gaze. The eyelids, lashes, glands and tumors are also examined for abnormalities.

1. Ocular Examination in Cataract
Evaluation:
By Dr Akash Patil
Goa Medical College

2. Head posture
• Abnormal head posture(AHP):
– Motor adaptation to strabismus
– Occurs primarily in children with congenitally
abnormal eye movements who use AHP to
maintain binocular single vision(BSV) and diplopia
– Loss of AHP indicates loss of BSV and need surgical
intervention
– Head is turned into the direction of action of weak
muscles so that eyes move opposite
direction(head will turn where eyes cannot)

3. Components of AHP
• Face turn:
– Adopted to control purely horizontal deviation
– In left lateral rectus palsy, face wil be turned to
left which deviates the eye to right
– In Paresis of right superior oblique face is turned
to left to avoid side where vertical deviation is
greatest

4. Right lateral rectus palsy( right face
turn)

5. Components of AHP
• Head tilt:
– Adopted to compensate for torsional and/or
vertical diplopia
– In right superior oblique weakness, right eye is
relatively deviated and the head is tilted to left:
this reduces vertical separation of diplopic images
and permits fusion

6. Left superior oblique palsy( right head
tilt, right face turn, chin depressed)

7. Components of AHP
• Chin elevation or depression:
– Adopted to compensate for elevator or depressor
weakness or to minimise the horozontal deviation
when an A or V pattern is present

8. Superior rectus palsy( chin lift)

9. Facial Asymmetry
• Dental asymmetry: loss of deciduous teeth,
congenitally missing teeth, habits
• Skeletal asymmetry: any bony abnormality on
one side of face
• Muscular asymmetry: hemifacial atrophy or
cerebral palsy, abnormal muscle function
• Functional asymmetry: defects in temporo
mandibular joint

10. Facial Asymmetry

11. Visual axis
• Visual axis : line of vision ; extending from the
point of fixation to the fovea
• Strabismus: misalignment of the visual axes
• orthophoria :perfect alignment of the visual
axes. Most individuals have heterophoria

12. Visual axis
• Clinical parameters to look for in ocular deviation:
• Direction of deviation:
– Heterophoria : (latent squint) tendency of the eyes to deviate.
Ocular alignment maintained with effort.
– Heterotropia : (manifest squint) which is present at all times
– Esophoria: latent squint inwards turning of the eyes
– Esotropia: manifest squint inwards turning of the eyes
– Exophoria: latent squint outwards turning of the eyes
– Exotropia: manifest squint outwards turning of the eyes
– Hyperphoria/hypertropia: latent/manifest squint upwards
turning of eyes
– Hypophoria/hypotropia; latent/manifest squint downwards
turning of eyes
• Frequency( latent, manifest, intermittent, constant)
• Comitancy ( comitant or incomitant)
• Laterality( unilateral, alternating)

14. Tests for visual axis
• Cover test: cover apparently fixing eye and watch movement of
suspected deviating eye. Establishes presence of true deviation;
latent or manifest; intermittent or constant; alternating or
unilateral; convergent or divergent; comitant or incomitant
• Cover-Uncover test: watch movement of eye immediately after
removing cover from that eye. Differentiates comitant from
incomitant
• Alternate cover: quickly cover each eye alternately and watch
behaviour of each eye when the cover is removed and transferred
to other eye. Converts phoria into manifest squint
• Hirshberg test: shine light of a torch on nasion of patient asking
him to fixate on the light and watch for symmetry of the corneal
reflexes

15. Cover uncover test Hirshbergs test

16. Ocular movements
1. Uniocular Eye Movemnts
– Duction
2. Binocular Eye Movements
– Version: (Binocular Conjugate Eye Movements).
– Vergence:(Binocular Disjugate eye movements)

17. Ocular movements
• Ductions – only one eye is open, the other
covered/closed tested by asking the pt. to follow
a target in each direction of gaze.
– Types of ductions:-
1. Adduction
2. Abduction
3. Elevation
4. Depression
5. Intortion
6. Extortion

18. Ductions

19. Ocular movements
• Versions:
– Both eyes open, attempting to fixate a target and
moving in same direction.
– Binocular ,simultaneous, conjugate movements in
same direction.
– Abduction of one eye accompanied by adduction
of other eye is called conjugate movements.

20. Ocular movements
Types of versions:-
• Dextroversion & levo version
• Elevation & depression
• Dextro elevation & dextro depression
• Levo elevation & levo depression
• Dextrocycloversion & levocycloversions

21. Ocular movements
• Vergences:
Binocular, simultaneous, disjugate/disjunctive movements
(opp.direction)
– Convergence– simultaneous adduction
– Divergence– outward movement from convergent
position

22. Versions and Vergences

23. Cardinal positions:-6
• 6 cardinal positions :- to test 12 EOM in their
main field of action
1. Dextroversion
2. Laevo version
3. Dextro elevation
4. Leavo elevation
5. Dextro depression
6. Laevo depression

24. 6 cardinal positions

25. Diagnostic positions of gaze:-9
• 1 Primary position of gaze:-assumed by eyes when fixating
a distant object with head erect.
• 4 secondary
1. up,
2. down,
3. Right,
4. Left,
• 4 tertiary positions
1. Dextroelevation,
2. Dextrodepression,
3. Levoelevation
4. Levodepression

26. Diagnostic positions of gaze:-9

27. Synergists, Antagonists, Contralateral
antagonist, Yoke muscle
• Synergists:-ref.to muscles having same action
in same eye.
– Ex:-sup.rectus & inf.oblique----elevators
inf.rectus&sup.oblique-----depressors
• Antagonists:-having opp.action in same eye
– Ex:-sup.&inf. Recti ,sup.&inf.oblique
• Contralateral antagonist:-pair of muscle (one
from each eye)having an opposite action.
– Ex:-in dextroversion RLR & LLR

28. • Yoke muscle(contralateral synergists):-
– Ref. to muscles which are primary muscles (one
from each eye) that accomplish(contract) a given
version.
– Ex :-in dextroversion RLR &LMR

29. Laws of ocular motility
1. Hering’s law of equal innervation:-
– During any conjugate movement equal &
simultaneous innervation flows to yoke muscles

30. Laws of ocular motility
2. Sherrington law of reciprocal innervation :-
• Increase innervation to an EOM is
accompanied by reciprocal decrease in
innervation to its antagonist.
• Ex:-RMR & RLR

31. Ocular margins:
• Involved in fractures and bony tumors
• Look for
– Tenderness
– Irregularity
– Crepitus

32. Eyebrows
• Level
• Form: synophrys is a condition where eye
brows are joined. Associated with
hypertrichosis
• Color: canities is physiological greying of hair
whereas poliosis is pathological greying
• Loss of lateral 1/3 rd of brow hair is know as
madarosis. Seen in leprosy, hypothyroidism,
chemotherapy

33. Eyelids and Eyelashes
• Body of the lid
– Thickness
– Uniformity
– Lesions
• Location in relation to cornea and pupil: upper lid margin
rests 2 mm below the limbus and lower lid rests at the
limbus
• Width of palpebral fissure
• Margins and eye lashes: Eye lashes are arranged in 2-3
rows; in upper lid they are directed forward, upward and
backwards; and in lower lids, forward, downward and
backwards
The edge of the lids are in apposition to eyeballs

34. Eyelids and Eyelashes
• Edema of lids:
– Inflammatory: dermatitis, stye, insect bite,
inflammations of conjunctiva and lacrimal sac,
chronic thickening in erysipelas
– Passive: renal or cardiac failure, angioneurotic
edema
• Inflammations of lids: blepharitis(anterior and
posterior), allergic dermatitis

35. Lid edema Blepharitis
Meibomian
pouting
Scaly
flakes
over
lashes

36. Eyelids and Eyelashes
• Inflammations of glands of lids: stye/external hordeolum,
hordeolum internum, chalazion
• Anomalies of position of lashes and lids:
– Blepharospasm
– Trichiasis ( misdirection of cilia backwards)
– Entropion ( rolling inwards of lid margins)
– Ectropion ( eversion of lid margins and lashes away from globe),
– Symblepharon (adhesion of lids with the globe)
– Ankyloblepharon ( adhesion of margins of lids)
– Blepharophimosis ( smaller palpebral fissure)
– Lagophthalmos ( incomplete closure of the palpebral aperture
when an attempt is made to shut eyes)
– Ptosis ( drooping of eyelids)

37. Stye/ ext hordeolum
Chalazion
Internal
hordeolum
Pus
point
Inflammed
chalazion

38. ,,
Adhesion of
margins of lids
Fibrosis b/w lid
and globe
Smaller
palpebral
aperture
(normal:
vertical
10mm and
horizontal
30mm
Symblepharon
Ankyloblepharon
Blepharophimosis
Trichiasis
Ectropion
Entropion
Misdirecti
on of
lashes
Eversion
of lid and
lashes
Inward
rolling of
lids

39. Ptosis Lagophthalmos
Drooping of lid
Incomplete lid
closure on
attempted
shutting of eye
Note upward
rolling of eyeball
suggesting good
Bell’s
Phenomenon

40. Eyelids and Eyelashes
• Tumors of lids:
– Benign growths- xanthalesma or xanthoma( raised yellow plaques),
nevus/moles, hemangiomas, neurofibromatosis
– Malignant growths- basal cell carcinoma, squamous cell carcinoma, kaposis
sarcoma, malignant melanomata
• Injuries of lids: contusions, wounds, burns
• Congenital anomalies of lids:
– Distichiasis( extra posterior row of cilia),
– Coloboma of lids( notch in the edge of lids),
– Cryophthalmos( skin passing continuous from brow over the eye to cheek),
– Microblepharon( abnormally small lids),
– Epicanthus( semilunar fold of skin covering the inner canthus)
• Age related changes: wrinkles, large skin folds, fullness, dermatochalasis
( loose folds of skin and muscles due to weak connective and elastic
tissue)

41. Xanthelasma Distichiasis
Basal cell ca Coloboma
Extra
posterior
row of
lashes
Defect
in
upper
lid
margin

42. Microblepharon
Dermatochalasis
Epicanthus
Abnormally
small lids
Semilunar
fold of
skin over
medial
canthus
Age related
loose fold of
upper lid skin

43. Conjunctiva
• To examine conjunctival sac it is necessary to
expose palpebral conjunctiva and fornices
• Lower fornix exposed by drawing lower lid
down while patient looks up
• Upper palpebral conjunctiva is exposed by
everting the upper lid

44. Conjunctiva
• Eversion of upper lid- A probe or pencil is placed along
skin of upper lid at upper border of tarsus while patient
is looking at his feet. Eye lashes are grasped b/w index
finger and thumb, drawing lid away from the globe. Lid
is rotated in vertical direction round the probe, and the
probe is withdrawn
• Double eversion- to view upper fornix. Ideally done
under LA. Lid retractor is placed anterior to already
everted lid, above the superior border of tarsus. Lashes
are used to evert lid onto the retractor, which is then
gently pulled away from the globe

45. Eversion of lids Double eversion
Desmarres
retractor over
anterior lid surface

46. Conjunctiva
• Examine for
Congestion
• Redness, leaving a relatively white zone around cornea with mucus/
mucopurulent discharge is indicative of conjunctivitis
• If associated with irritation,photophobia, lacrimation and
blepharospasm- look for FB, misplaced lashes, corneal abrasion,
erosions, ulcers or keratitis. Vessels in circumcorneal zone are bright
red with dilated corneal loops of limbal plexus
• Ciliary congestion- In inflammations of iris and sclera, pink
perilimbal injection is supplemented by a dusky, liliac tint due to
congestion of deeper, anterior ciliary vessels
• Ciliary congestion vs conjunctival congestion- congestion decreases
after instillation of 10% phenylephrine; blanches on digital pressure
through lids, vessels fill from fornix inwards on releasing pressure in
conjunctival congestion

47. Conjunctival congestion Ciliary congestion

48. Conjunctiva
• Presence of foreign bodies
• Papillae/follicles-
– papillae: cobblestone arrangement of flattened nodules with
central vascular core. Seen in vernel and atopic
kertoconjunctivitis, contact lens or ocular prosthesis
– Follicles: small dome shaped nodules without a prominent
central vessel. Seen in viral and atypical bacterial conjunctivitis,
toxin and topical medications like brimonidine
• Cysts
• Concretions- small, hard, yellowish white calcified matter,
buried beneath palpebral conjunctiva
• Tumors
• General status of ocular surface and tear film

49. Papillae Concretions
Follicles
cysts
Cobblesone
appearance
Dome
shaped
nodules

50. Sclera
• Episcleritis- raised, congested, painless nodules around
cornea
• Deep scleritis- deep red, dusky congestion associated
with peripheral keratitis and uveitis
• Definite blue coloration of circumcorneal sclera is
pathological except in very young children. Seen in
staphylomata, scleral ectasia with herniation of uveal
tissue owing to weakness of sclera following injury or
scleritis, increased IOP
• Pigmentation around the points where anterior ciliary
vessels perforate sclera indicates melanosis. Slight
duskiness in people with dark complexion is common

51. Episcleritis Scleritis

52. Cornea
• Corneal surface-
– Placido keratoscopic disc used to assess corneal surface
– Has alternating black and white painted circles. Observer
looks through a hole in the center at corneal image
reflected by a light behind patient
– Loss in sharpness of the outline of the image denotes a
loss of polish of corneal suface
– Irregularities in rings reflect irregularities of corneal
surface
– Similarly , posterior surface of cornea, the anterior
chamber and lens can be imaged using slit scanning
technology like Orbscan

53. Placido keratoscopic disc

54. Cornea
• Corneal epithelium-corneal staining with vital
dyes. 3 dyes are used
– Fluorescein is useful in delineating denuded
epithelium( abrasions, multiple erosions, ulcers) , stain
brilliant yellow green when seen with cobalt blue light
– Rose bengal stains diseased and devitalised cells red
(superficial punctate keratitis)
– Alcian blue dye stains mucus selectively delineates
excess mucus produced when there is deficiency in
tear formation

55. Fluorescein dye Rose bengal

56. Cornea
• Corneal opacities- best studied with slit lamp
– Epithelial or subepithelial Superficial punctate
keratitis
– keratic precipitates: small accumulations of
inflammatory cells derived from uvea- appear
white, round and dome shaped when fresh
– Mutton fat keratic precipitates: large, waxy KPs are
seen in granulomatous uveitis
– Fine KPs are present in Fuchs cyclitis and herpes
zoster uveitis

57. Superficial punctate keratitis Mutton fat keratic precipitates
Keratic precipitates

58. Cornea
• Corneal endothelium-
– Specular examination technique on slit lamp
– Objective examination by specular microscopy:
average cell count is 2800/mm2. identifies
pleomorphism( decrease in cell density) and
polymegathism( variation in cell size)
– Confocal microscope: shows endothelial and epithelial
cells, keratocytes
– Endothelial cell count is done before corneal grafting
– Abnormal cell count if less than 1500/mm2

59. Cornea
• Corneal vascularisation
– Superficial vessels: can be traced over the limbus into
conjunctiva. They are bright red and well defined.
Branch dichotomously in an arborescent fashion. They
may raise epithelium over them and make corneal
surface uneven
– Deep vascularisation: end abruptly at limbus. They are
ill defined, greyish red or diffuse red blush. They run
more or less parallel in radial direction. Branching is at
acute angle and their course is determined by the
lamellar structure of substantia propria. Though hazy,
surface is smooth

60. Superficial corneal vascularisation
A.Superfial
B.Terminal loop
C.Brush type
D.Umbel type

61. Deep corneal vascularisation

62. Cornea
• Corneal sensitivity-
– Wisp of a cotton or aesthesiometer(objective)
– Brisk reflex closure of lids
– Diminshed after any gross disorder
– Herpes keratitis: minimal corneal changes are
associated with gross diminution of sensations

63. Corneal sensitivity test with wisp of
cotton

64. Cornea
• Corneal curvature: measured by keratometer
• Corneal thickness: measured by optical
pachymetry on slit lamp or ultrasonic
pachymetry

65. Anterior chamber
• Anterior chamber depth:
– Shallow in very young and in old age
– Normal depth is about 2.5 mm
– Measured as distance b/w posterior surface of
cornea and anterior surface of lens
– Clinically evaluated by focussing beam of light on
temporal limbus, parallel to iris surface. In normal
or deep anterior chamber the beam will pass
through directly, illuminating opposite limbus

67. Anterior chamber
• Anterior chamber depth….
– Van herrick method: an optical section of peripheral
cornea and anterior chamber is made on slit lamp
with illumination and viewing arms 60 degrees to
each other, and viewing arm perpendicular to cornea,
with magnification of 15. If anterior chamber depth is
equal to or less than 1/4th of thickness of cornea,
angle closure is possible. If anterior chamber is more
than half the corneal thickness, closure is unlikely
– Objective measurement is by pachymetry on slit lamp
or Orbscan II usg

69. Anterior chamber
• Anterior chamber depth..
– Shallow in angle closure glaucoma
– Deeper in periphery than in the center in
iridocyclitis
– Deep in center and shallow in periphery with
funnel shaped ,bowed forward iris as in iris bombe
– Subluxation of lens causes chamber to be deeper
on one side
– Deepening seen adjacent to angle recession
following trauma

70. Anterior chamber
• Aqueous cells- seen in active uveitis
– Graded by counting number seen in a 2 by 1 mm
slit
– Trace if 1-5 cells present
– 1+ if 5-10 cells
– 2+ if 10-20 cells
– 3+ if 20-50 cells
– 4+ if >50 cells

71. Anterior chamber
• Aqueous flare:
– Protein exudation from the iris or ciliary vessels
produces opalescence of the aqueous
– Graded as 1+ if barely present
– 2+ if moderate
– 3+ if obscures visualisation of the iris pattern
– 4+ if fibrin is present in anterior chamber

72. Anterior chamber
• Hypopyon-
– In infected wounds and ulcers of cornea,
iridocyclitis, there is collection of lymphocytes in
anterior chamber forming a sediment at the
bottom
• Hyphema
– Collection of blood after contusions or
spontaneously
• Microfilariae seen in anterior chamber in
onchocercias

73. Hypopyon Hyphema
Collection of
lymphocytes in anterior
chamber

74. Iris
• Color and clarity of iris pattern:
– Hetrochromia iridium or iridis- two irides or parts of
same iris may be different color
– A dull, ill defined pattern or muddiness of iris suggests
atrophy from iridocyclitis
– Sectoral atrophy suggests an acute angle glaucoma or
herpes zoster
– Freckles: flat darkly pigmented spots
– Brushfield spots in downs syndrome
– Pedunculated nodules(Lisch) in neurofibromatosis
– In acute angle closure glaucoma, pupil is large,
immobile, oval with long vertical axis

75. Heterochromia iridis Brushfield spots
Sectoral iris atrophy Leish nodules

76. Iris
• Color and clarity of iris pattern:…
– Flat nodules at pupillary margin(koeppe nodules)
or at the peripheral base of iris(busacca nodules)
– Muddy iris with a small, irregular pupil, sluggishly
reacting to light indicates uveitis

77. Koeppes nodules Iris in uveitis
Busaca nodules

78. Iris
• Position of iris:
– Examine the plane
– Adhesions or synechiae, anterior to cornea and
posterior to lens capsule
– Tremulousness of iris or iridodonesis is seen when
eyes are moved rapidly, seen in absence,
shrinkage, or subluxation of the lens. Best
appreciated in a dark room with oblique
illumination

79. Pupils
• Examination of pupils should be done before any
mydriatic is put
• Illumination in examination room should be low
• Patient should look into the distance- to prevent
accomodative constriction of pupil
• Light used should be focussed and bright
• Size, shape, contour of each pupil should be
noted
• Pupillary reflexes

80. Pupils
• Pupillary reflexes:
– Direct reaction to light: cover both eyes. While
patient looks straight ahead remove one hand
watch the pupil. Watch if its constriction is well
maintained. Replace this hand removing the other
and observe other pupil
– Consensual reaction to light: remove one hand so
that pupil is exposed to light and watch the other
pupil as the hand is removed from other eye

81. Pupils
• In absence of natural or diffuse illumination or when
reaction is feeble and pupils are small: examination is
carried out in a dark room. Light is concentrated upon
one pupil by focal illumination so that light shines upon
macula to elicit light relfex. Focus of light can be moved
on and off the pupil and movements noted constantly.
• Still finer observations can be done by slitlamp by
moving beam of light abruptly into pupillary aperture
• This method is utilised in eliciting wernickes
hemianopic pupillary reaction where brisk reaction is
there when one half of retina is illuminated but
sluggish on illuminatinf other half

82. Pupils
• Swinging flashlight test
– Bright light is shone on one pupil and constriction noted.
After 2-3 seconds light is rapidly transferred to other pupil.
Response is noted with swinging to and fro repeated
several times
– Direct and consensual response are of same magnitude
– In lesion of optic nerve light transferred to diseased eye
leads to dilatation of both eyes and on swinging back to
normal side both pupils will constrict: Marcus gunn pupil
or relative afferent pupillary defect(RAPD)
– Convergence and accomodation reflex: patient looks at far
end and a target is suddenly held up vertically at 15 cm
from patients nose. Movement of pupils studied while he
converges

83. Swinging flashlight test

84. Pupils
• Abnormal pupil size:
– Dilatation of pupils with retained reflexes is found in myopes, impaired
tone or nervous excitement
– Small pupils are seen in babies and old people
– Very large, non reactive pupils suggest that a mydriatic was used:
dimness of vision for near work noted by patient
– Large and immobile pupils noted in bilateral lesions affecting the
retina and optic nerve atrophy.
– Large , immobile pupils also result from third nerve palsy.
Accomodation is also affected if third nerve fibres to ciliary muscles is
affected( third nerve nucleus lesions, meningitis, encephalitis, cerebral
syphilis, diphtheria, lead poisoning, trauma affecting third nerve,
ciliary ganglion
– Bilateral blindness distinguished from bilateral efferent pupillary
defect by elicitng near reflex. Patient attempts accomodation by
propriception as thumb is held in front of him

85. Pupils
• Abnormal pupil size…
– Blindness with retained direct reflex is seen in lesions above the level
of lateral geniculate body( postbasal meningitis, hemorrhage, uremia,
bilateral occipital lobe infarction)
– Opacities in media like cataracts and vitreous hemorrhages never lead
to absent pupillary reflex
– Unilateral dilatation results from irritation of sympathetic nerves. Seen
in swollen lymph nodes in neck, apical pneumonia, apical pleurisy,
cervical rib and thoracic aneurysms, syringomyelia ,poliomyelitis
affecting lower cervical and upper thioracic parts of spinal cord.
Conditions causing irritative dilatation leads eventually to constriction
from sympathetic paralysis
– Horner syndrome: sympathetic function on one side is lost leading to
miosis, enophthalmos( due to loss of muller muscle tone), unilateral
absence of sweating( anhydrosis)

86. Pupils
• Abnormal pupil size:
– Small immobile puils seen in use of drugs like
miotics locally and morphine systemically, Old
iritis with posterior synechiae
– Small, sluggish pupil with muddiness of iris
suggests active iritis
– Bilateral small pupil may be due to irritation of
third nerves due to CNS disease in vicinity, palsy of
sympathetic system as in pontine hemorrhage

87. Pupils
• Abnormal pupillary reflexes:
– Loss of light reflex from lesions of retina and optic
nerve
– Hemianopic reaction due to lesions in tract
– Third nerve lesion abolishes both light and
convergence reflexes
– Argyll robertson pupil: damage to relay paths in
the tectum mostly syphilitic. Pupil do not react to
light but convergence is retained( light near
dissociation)

88. Pupils
• Abnormal pupillary reflexes:..
– Tonic pupil of adie: seen in young females, often
unilateral and associated with absent knee jerk.
Pupil is slightly dilated. Light reflex as vermiform,
slight constriction. Convergence is sluggish, Latent
period is increased. Tonic pupil dilates well with
atropine and constricts with 0.1% pilocarpine

89. Lens
• Oblique illumination exam: reveals color of lens in
pupillary area
• Iris shadow:
– Sign of immature catarct.
– When an oblique beam of light is thrown on pupil, a
crescentic shadow of pupillary margin is formed on
the greyish opacity of the lens as long as clear cortex
is present in between the opacity and pupillary
margin.
– Not seen in transparent or completely opaque lens

90. Iris shadow
crescentic
shadow of
pupillary
margin

91. Lens
• Direct distant ophthalmoscopy: a reddish yellow
fundal glow is seen in absence of any opacity.
Partial cataractous lens shows black shadow
against the red glow. No red glow in complete
cataractous lens
• Slit lamp biomicroscopy reveals opacity( site, size,
shape, color pattern and hardness of nucleus).
Grade of nucleus hardness is important for
setting parameters of phacoemulsification
machine

92. Grading of nucleus hardness on slit
lamp:
Grades of hardness Description of hardness Color of nucleus
Grade I Soft White or greenish yellow
Grade II Soft medium Yellowish
Grade III Medium hard Amber
Grade IV Hard Brownish
Grade V Ultrahard blackish

93. Visual acuity
• Visual acuity is noted : test one eye at a time
– Unaided
– Best corrected
– Pin hole
• Perception of light(PL): absence of PL indicates nil visual prognosis
• Projection of rays: thin beam of light thrown in patients eyes from 4
direction( up, down, medial and lateral). Patient is asked to look
straight ahead and point direction from which light is coming.
Inaccurate PR is due to old RD, visual pathway defects, advanced
glaucoma, chorioretinal atrophy. Indiacates poor visual prognosis
• Potential visual acuity tests: done in opaque media
– Laser interferometer
– Potential acuity meter
• Near vision: jaegers chart

94. Snellen’s chart Jaeger’s chart

95. Intraocular pressure
• IOP is pressure exerted by the intraocular contents on
coats of the eyeball
• Normal IOP: 10-21 mm hg ( mean 16+/- 2.5 mm hg)
• IOP is measured by
– Digital tonometry- rough estimate of IOP by fingertips in
uncooperative patients
– Indentation tonometry:works on principle that plunger will
indent soft eye more than a hard one
– Applanation tonometry: based on Imbert –Fick principle
• Eye needs to be anesthetised before indentation and
applanation tonometry

96. Digital tonometry
Schiotz indentation tanometry
Applanation tonometry

97. Lacrimal system
• Lacrimal sac syringing:
– After instillation of topical anesthetic, lower
punctum is dilated
– Irrigation cannula is placed in canaliculus
– Lateral retraction of lower eyelid to prevent
canalicular kinking
– Clear saline is injected
– Patient is asked if he can taste the saline and
watch for any reflux

99. Possible results from lacrimal
apparatus irrigation/ localization of
obstruction
• Normal: irrigated fluid tasted by patient
• Complete obstruction: no fluid tasted, all fluid
refluxed through opposite punctum
• Partial obstrcution: some fluid tasted, most of
the fluid refluxed through opposite punctum
• Canalicular obstruction: no fluid tasted, all of
the fluid refluxed through same punctum
• Dacrocystitis: no fluid tasted, mucoid fluid
refluxed through opposite punctum

100. Complete canalicular obstruction. The cannula is advanced with
difficulty, and irrigation fluid refluxes from the same canaliculus

101. Complete common canalicular obstruction. A "soft stop" is encountered
at the level of the lacrimal sac, and irrigated fluid ref luxes through the
opposite punctum.
Soft stop is a spongy feeling due to canalicular obstruction

102. Complete nasolacrimal duct obstruction. The cannula is easily advanced
to the medial wall of the lacrimal sac, then a "hard stop" is felt, and
irrigation fluid ref luxes through the opposite punctum.
If the probe touches the medial orbital wall, this means Hard Stop.

103. Partial nasolacrimal duct obstruction. The cannula is easily placed, and
irrigation fluid passes into the nose as well as refluxing through the
opposite punctum.

104. Patent la crimal drainage system. The cannula is placed with ease, and
most of the irrigation fluid passes into the nose

105. Fundus exam:
• Fundus exam to be carried out to rule out
other causes of decreased vision
• Indirect ophthalmoscopy to be done in hazy
media

106. Macular function test
• To predict the visual potential in patients with
very dense cataract where fundus exam is not
possible
– Two light discrimination test: patient looks through an
opaque disc perforated with 2 pinholes behind which
a light is held. Holes are 2 inches apart and kept at 2
feet away from the eye. If patient perceives 2 lights, it
indicates normal macular function
– Maddox rod test: patient looks at a distant bright light
through a maddox rod. Accurate perception of red line
suggests normal function

107. Macular function test
• Colour perception: normal colour vision
suggests some macular function is present
and optic nerve is relatively normal
• Entopic visualisation: patients closed eyes are
rubbed with a point source of light. If patient
perceives the retinal vascular pattern in black
outline, it indicates normal retinal function

108. Thank you!!