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ANTERIOR SEGMENT EXAMINATION.PPTX.......
The document outlines a comprehensive approach to anterior segment examination, detailing key examination elements such as visual acuity, intraocular pressure, and inspection of various ocular components including the eyelids, conjunctiva, cornea, and lens. It emphasizes the importance of thorough visual assessment and documentation of findings, particularly in identifying conditions like keratoconus and ocular surface neoplasia. Additionally, it discusses relevant investigative methods that may be employed based on clinical findings.
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ANTERIOR SEGMENT EXAMINATION.PPTX.......
- 1. Anterior Segment Examination ByBabli Sharma B.Optom, M.Optom
- 2. Examination Outline • Visualacuity, IOP, Inspection, Refraction • Lids, Lashes, Lacrimal structures • Conjunctiva/Sclera • Cornea • Anterior Chamber • Pupil • Iris • Lens • Anterior vitreous
- 3. Examination Structure • Attentionshould be given to the wording of the question which often directs the candidate where to look: “Examines the”… External Eye – Periorbital tissue, • Eyelid, margins, • Conjunctiva, • Fornices, • Limbus and Corneal surface • Anterior Segment – • Eyelids, • Conjunctiva, • Cornea (all layers), • Anterior chamber, • Iris and Lens
- 4. Visual Acuity, IOP,Inspection, ± Refraction • Always stand back and examine the patient as a whole. • Age / gender / ethnicity are often useful in narrowing the potential differential diagnoses. • Iris heterochromia, symblepharon, ankyloblepharon and forniceal shortening are often more obvious on gross inspection before beginning the slit lamp examination. Iris heterochromia Symblepharon Ankyloblepharon
- 5. Lid, Lashes, LacrimalStructures • Blepharitis, • Ectropion / entropion / punctum • Madarosis / hypertrichiasis • Scarring from HZO / pigment changes Madarosis Hypertrichiasis Scarring from HZO
- 6. Conjunctiva/Sclera • Ask thepatient to ‘Look up’ (while pulling the lower lid down): Symblepharon / ankyloblepharon / forniceal shortening • Ask the patient to ‘Look down’ (while pulling the upper lid up): Trabeculectomy bleb / glaucoma drainage device • Scleral buckle • Offer to evert the upper lid Trabeculectomy bleb
- 7. Cornea • Always markthe visual axis. • Always draw a cross-section with corneal epithelium / stroma / endothelium, iris and lens. • It is important to document the level, size, shape and location of any corneal lesion. Cross section of cornea diagram
- 8. Note: • Shape: e.g.Keratoconus • Size: Measure the corneal diameter with a handheld ruler if suspicious of congenital glaucoma. Greater than 12mm in an adult is abnormal, Microcornea is defined as corneal diameter <10mm • Thinning: Estimate and document the remaining thickness as a % of normal • Scars, wounds Keratoconus Microcornea Megalocornea: suspicious of congenital glaucoma
- 9. Contd.. • Corneal graft i.Type (penetrating vs. anterior lamellar vs. endothelial)? Size? Clarity? ii. Sutures? (interrupted, continuous, broken / loose?) iii. Pay special attention to the graft-host junction iv. Neovascularisation? v. Look at the other eye for clues as to why the patient had a graft • ± Tear film / marginal tear strip Sutures Neovascularisation
- 10. In addition, lookat each corneal layer: Epithelium: • Epithelial defects, • punctate epithelial erosions, • superficial punctate keratitis, • dystrophies, • microcystic oedema, • Fleischer ring, • limbal stem cell failure (conjunctivalisation of the cornea) Epithelial defect Punctate epithelial erosions Superficial punctate keratitis Dystrophies
- 11. Contd.. Stroma: • Dystrophies, • stromaloedema, • vessels (superficial or deep?), • prominent corneal nerves Endothelium: • Guttata, • pigment dispersion, • keratic precipitates (KP), • Descemet’s membrane folds Prominent corneal nerves Pigment dispersion
- 12. Contd.. • The presenceof one sign (e.g. a conical cornea) • Should prompt you to look for other associated signs of that condition: e.g. • Down syndrome, • Vernal kerato-conjunctivitis, • Fleischer ring- best seen with cobalt blue light, • Prominent corneal nerves, • Hydrops / corneal scarring and Vogt striae of keratoconus). VKC Hydrops Vogt striae Down syndrome
- 13. Contd… • If anocular surface mass is present (e.g. Ocular surface squamous neoplasia : OSSN), • We must exclude orbital invasion. Check for: • Lymphadenopathy • Corneal sensation • Ophthalmoplegia • Intraocular examination including gonioscopy for angle involvement OSSN Ophthalmoplegia
- 14. Anterior Chamber • Cells/ flare • Hypopyon, hyphaema • Anterior chamber depth (narrow angle?). Von Herrick’s test can estimate angle depth If an intraocular mass is present (e.g. iris melanoma), then check for: • Hyphaema • Nodular vs diffuse configuration • Ectropion uveae – seen in iris melanoma • Refractory glaucoma - raised IOP • Gonioscopy for angle involvement • Transillumination – more likely to be a cyst • Subjacent ciliary body involvement – will need eye to be dilated • Dilated fundus examination for extension posteriorly Hypopyon Hyphaema
- 15. Iris • Posterior bow(pigment dispersion syndrome PDS) • Rubeosis (neovascular vessels run parallel to pupil rather than radially and are uncuffed) • Transillumination defects: Peripheral iridotomy (PI), PXF, PDS, HZO, trauma (IOL, ACG) Rubeosis Peripheral iridotomy PXF
- 16. Lens • Cataract: Whattype? Anterior cortical / Nuclear sclerotic / Posterior subcapsular • Phacodonesis? (ask the patient to ‘look up’ then ‘look straight’). Anterior or posterior lenticonus • IOL (PCIOL in bag / sulcus, open-loop ACIOL, iris clipped, scleral fixed- sutured vs. tunnelled) • Posterior capsular opacification / YAG capsulotomy • PXF, posterior synechiae, glaucomflecken Cataract PCIOL Posterior Synechiae
- 17. Anterior Vitreous • Tobaccodust • Asteroid hyalosis Asteroid hyalosis
- 18. General Comments Record importantnegatives : • (e.g. absence of hypopyon / • synechiae in infection). Consider further examination / testing: • fluorescein staining, • corneal sensation, • Schirmer’s test.
- 19. Things Not toMiss (or to Look for if You Can’t Find Anything) • Symblepharon, forniceal shortening • Trabeculectomy bleb, glaucoma drainage tube, MIGS • Keratoconus • Corneal guttata (Fuchs endothelial dystrophy) • Cells / flare • Transillumination defects (PI) • LASIK flaps • PXF
- 20. Investigations Investigations will bedictated by findings, but may include: • Corneal scrape / biopsy / impression cytology • Confocal microscopy • Corneal topography / Keratometry • Corneal pachymetry • Anterior segment optical coherence tomography (OCT) • Ultrasound biomicroscopy (UBM)
- 21.