This clinical document provides an overview of various ophthalmic examination techniques, diagnostic tools, pathologies, and treatment plans for 4th grade students. It discusses topics such as visual acuity testing in children, anterior segment examination, lens pathology, glaucoma, trauma, and ocular oncology. Examination methods covered include the Snellen chart, pinhole testing, trial lenses, Amsler grid, and color vision testing. Common conditions described are cataracts, retinal detachment, optic disc edema, and cellulitis. Surgical procedures like penetrating keratoplasty and dacryocystorhinostomy are also mentioned.

1. Clinical for 4th Grade
students
Ahmed Osama Hashem
FRCS ophth
PhD,MD Ain Shams university
Lecturer of ophthalmology

2. Snellen chart- illiterate E –OR Landlot broken
C

3. Pinhole

4. Trial
• Trial frame ,, trial lenses

5. Test macula function (Amsler grid)

6. Age related Macular degeneration-Wet type
(CNV)with hemorrhage and scar

7. Test contrast sensitivity

8. Test color vision

9. Test VA in children
• Picture test

12. Test VA in children
• preferential looking

13. Test VA in children
• hundreds and thousand test sweet test

14. Anterior blepharitis
1. Seborrheic (scaly)

15. Bilateral ptosis

16. Complications of blepharitis(Madarosis–poliosis-
ptylosis …….

17. Phoropter

19. Nebula

22. Leukoma

23. Desmatocele

24. Leukoma Adherant

25. Leukoma Adherant- Irregular pupil

27. Anterior chamber flare

28. vWhat you can see at the bottom of the cornea ?
vWhat is the treatment ?
Mutton Fat keratic percepitates

29. vAnterior uveitis if not treated probably may
lead to sever complications, what are they ?
Festooned pupil posterior synechia

30. vWhat is your main finding?

31. vMention 3 abnormal findings ?
vMention the most common cause?

32. Rt Leukocoria

33. Cortical cataract (nearly complete cortical)

34. Nuclear cataract

35. Nuclear cataract
Increase in
refractive index
N=1.42
Red reflex
appears as a ring
around a nuclear
opacity

36. Nuclear cataract Vs Cortical cataract

37. Nuclear Brown Cataract

38. Hypermature cortical cataract
• A)Typical Hypermature.
• B)Morgagnian Type.

39. Morgagnian cataract

40. Focal blue dot Cataract
Extremely common and insignificant

41. Subluxated lens

42. Congenital or Developmental cataract

43. Morphological types
• Nuclear,,,, central,,,,+- Microcornea,Microphthalmia..

44. • Lamellar-Zonular
Opacity between clear Nucleus & Cortex

45. Sutural Cataract
• Follow Y sutures

46. Coronary cataract
• Opacity in deep cortex forming a crown like around the nucleus.

47. • Polar cataract:
-Anterior Polar:pyramidal projecting into AC,,,,
May accompany persistent pupillary membrane
Doesnot affect vision,,,,away from nodal point,,,

48. • Focal blue dot,,
Extremely common and insignificant

49. Subluxated lens

51. Intraocular Artificial lens

52. Complication of surgery
• PCO
• Posterior capsular opacification

53. IOL dislocated

54. Anterior Uveitis Keratic percepitate

55. Systemic diseases
• DM
-Presenile cataract ,,,senile in earlier stage
Good control of blood sugar,,ophthalm. Exam,surgery
-True diabetic cataract – relatively younger age-snow flake cataract.Ant
& Post flake like opacities.

56. • Hereditary. Retinitis pigmentosa,

57. Papilledema(optic disc edema)

58. 1- Intracranial causes:
A- Neoplasms 70 % are caused by brain tumors ,, Always
bilateral unless one nerve is atrophic,, (Foster kennedy
syndrome)
Frontal lobe
tumor
Optic disc edema on
one side and
primary optic
atrophy on the
other side

59. • Central retinal vein occlusion

60. Rt optic disc edema
Congested,tortous
retinal veins,,
Flame shaped He
Venous pulsation
disappear
Congested,tortous
retinal veins,,

61. Lt normal optic disc

62. • Post papilledemic optic atrophy

63. Glaucomatous optic atrophy

64. Glaucomatous optic atrophy

65. unilateral congenial severe ptosis

66. Rt leukocoria

67. Apparent squint

69. Cover uncover test

70. Synaptophore

71. Worth’s four dot test
five dots are seen, namely two red and three green in cases of
heterophoria.

72. Maddox rod and tangent scale test

73. The Maddox wing test

74. Cover test

75. Deviation of one eye Lt Exotropia( XT)

76. Rt 3rd N palsy

77. Lt 6th N palsy

78. Blow-out fractures of the orbit
• 1-(Periocular signs) include Black eye, edema and subcutaneous
emphysema.
• 2- Injury to the infraorbital nerve. This can cause hypoesthesia of the facial
skin of lower lid (Cheek anaesthesia).
• 3-Impingement of the inferior rectus can result in (Diplopia), The diplopia
typically occurs in both up-gaze and down-gaze (Vertical diplopia)
(Diplopia worse in upward gaze).
• 4- (Enophthalmos) is usually absent at the beginning because of associated
orbital edema or hemorrhage and, Enophthalmosmay develop after 10
days as the edema subsides.
5- uncommon, Intraocular ocular damage (e.g. hyphema, angle recession,
retinal detachment) should be excluded

79. vWhat is the diagnosis?
vMention 2 useful investigations?
Rt fracture orbital floor

80. vWhat is the diagnosis?
vThe most common cause is ………

81. This CT scan shows fracture of the orbital floor and
opacification of the maxillary sinus.
vSuch a patient usually complain of …………

82. Eye lid hematoma
(black eye)

83. Eye lid laceration

84. Eye lid laceration

86. Ectropion

87. Lagophthalmos

88. coloboma

89. Vertical mattress suture for full thickness
eyelid injury repair

90. vWhy this injury needs urgent repair?
Lacrimal canalicularinjury with nasolacrimal tube repair (Eagle Tube)

91. vAn injury like this should be done immediately
otherwise the patient will suffer from………..

92. Subconjunctival Hemorrhage
• Fragile vessels rupture from trauma,
Valsalva pressure spikes (sneezing,
coughing, retching),
hypertension,blooddiseases, or
without obvious cause.

93. Subconjunctival Hemorrhage
• Cornea not involved.
• Resolves within 2 weeks.

94. But take care
You should exclude (Rupture globe) Scleral wound

95. And you should exclude fracture skull base
DD Local ocular trauma Fracture base of skull
onset immediate Delayed
Trauma To eye ,no proptosis To head + proptosis
consciousness Normal Loss of consciousness
site Temporal Fornices
shape Triangular,base to the cornea Tringular,,apex to cornea
color Bright red Dark red
Posterior limit definite Is not seen

98. Corneal Abrasion
• Corneal abrasions often worsened by
rubbing and scratching.
• Foreign body sensation common.

99. This photo took after an injury to the right Eye
vTell me the complications
Rupture globe with iris prolapse Corneal Limbal wound

100. vDescribe the finding in this picture

101. vAngle recession glaucoma occurs after Blunt trauma

102. vWhat is the diagnosis ?
vMention the most common underlying cause ?

103. vWhat are the complications may follow this
trauma ?

104. Complication of hyphema
1-Secondary glaucoma (Open OR Close)
2-Blood stained cornea (5%) (need increase of IOP).
3-Decrease vision (due to cross pupil).
4-Recurrent hyphema (20%)(Secondary hyphema) within 3-5 days,
more common in Black people

105. vHow can you manage a case like this?

106. vWhat are your findings?
Iridodyalysis D shaped pupil

108. Adie’s pupil,,ciliary ganglia lesion

109. Ultra sound
biomicroscopy

111. Voissous Ring

112. Characteristic stellate (star shape)
appearance of traumatic cataract

113. Lens subluxation (Sunset)

114. Rosette shape cataract

115. vCommotio retinae is a complication of ……….

124. Retina Dyalisis from its Insertion

125. Choroidal rupture

126. Subretinal Hemorrhage-Suprachoroidal
hemorrhage

128. RT OPTIC DISC EDEMA AFTER TRAUAM

130. LT EYE COMPLETE OPTIC ATROPHY

131. vThis patient sustained trauma after ECCE,
describe the findings?

132. Perforating Injury
• Eye-threatening emergency requiring
emergency ophthalmologic surgical
intervention.
LT CORNEAL WOUND BY A KNIFE WITH
IRIS PROLAPSE

133. CORNEAL WOUND BY A KNIFE WITH
IRIS PROLAPSE
MY DEAR students please
notice the difference
between penetrating injury
and blunt one
Perforating injury

136. Corneal perforation repair

137. vWhat are the complications?
Metallic FB
penetration

138. Corneal Foreign bodyy

139. vWhat is your diagnosis ?
vWhat is the treatment ?
Corneal FB over the limbus

140. Fb in sulcus subtarsalis –corneal abrasion by Fluoresceine

141. Rust ring after FB removal

142. 142
vWhat is this test ?
vWhat does it indicate ?
River sign
Penetratin FB
injury

143. vWhat is your diagnosis ?
FB in the vitrous cavity

144. One of the
complications of
perforating eye injury
is endophthalmitis
with hypopyon

146. vWhat is the diagnosis?
vWhat is the treatment?
Lt FB intraocular by
Xray

147. Physical keratoconjunctivitis-phototoxicity-UV
photophthalmia
keratitis
+ve FL cobalt blue filter

148. True exfoliation :Infrared effect in ovens and
glassblowers
Pseudo exfoliation occur as a part of systemic
disease and lead to open angle glaucoma
Pseudoexf
oliation

149. Infrared (Glassblower Cataract)

150. Notice the effect of light energy over the photoreceptors in OCT

151. Vascularized cornel opacity

152. Vascularized cornel opacity

153. Cicatricial ectropion

154. Symblephron

155. vWhat is the medical treatment of sever
chemical injury ?
vAlkali burn more dangerous than acid burn.why?
Necrosis over
the limbus

156. Corneal
necrosis
after
chemica
burn

157. In chemical injury ,the first step is to irrigate the eye.
vWhat next ?

158. Lid speculum

159. Autograft

160. Amniotic membrane graft

161. Lysis of symblepharon

162. Penetrating keratoplasty

163. Boston Keratoprothesis

164. Keratoconus

165. Myopic fundus with temporal crescent
•

166. Chorioretinal atrophy Fuch’s spot

170. CNV hemorrhage in myopic fundus

171. Giant retinal tear

172. Fuch’s spot in myopic fundus

173. Periperal retinal break surrounded by Argon
laser

174. Mucormycosis
Fungal infection
over lt orbit and lt
maxillary sinus

175. Cavernous hemangioma vs capillary
(Age)Commenest benign MCQ..

177. Commonest Adult tumor ,,(Orbital lymphoma,, ,,
Salmon patch---Lscrimal gland) Malignant

178. Rt Proptosis

179. Rt non axial proptosis

180. Bilateral lid retraction DD bilateral proptosis

181. Lt lid retraction Vs Lt proptosis

182. Lt Non-axial proptosis

183. RTl axial proptosis with exposure keratopathy

184. Preseptal cellulitis

185. Orbital cellulitis

187. Exophthalmometry(Hertel)

188. Preseptal vs Orbital cellulitis CT

190. Rt Lower lid trichiasis

191. DD Rt corneal opacity -Buphthalmos

192. Rt Acute
Dacryocystitis

193. Rt Chronic Dacryocystitis

194. Lacrimal sac fistula

195. Lacrimal gland swelling- Lt Acute
dacryoadenitis

197. Lt lacrimal sac massage

198. Probing 1st punctum dilator

199. probing

200. Syringing

201. DCR

202. Rose Bengal staining of mucus, debris and
devitalized epithelial cells is observed in the
inferior cornea and bulbar conjunctiva

203. FL break up time test

204. Schirmer’s test

205. Schirmer’s test

206. Lt congenital Horner’s Syndrome with iris
heterochromia

207. Lt Horner’s syndrome (Ptosis –miosis -

209. Attenuation of arteries
Waxy disc pallor
Normal margin
Normal cup

211. Glaucomatous optic atrophy

212. Peripapillary atrophy in glaucoma.

214. Slit lamp + Gonio lens

215. 90 Diopter auxillary lens

216. Slit lamp + applanation tonometry

217. Applanation + FL

218. Digital method for IOP measurment

219. Tono pen

221. Confrontation test for the Lt eye

222. Visual field by projection

223. Pterygium

224. Rt diabetic retinopathy maculopathy

225. Rt diabetic retinopathy maculopathy

226. Lt diabetic maculopathy

227. Vitrous pre retinal hemorrhage

229. Lt Hypertensive retinopathy

230. vWhat is your diagnosis ?
vMention the ttt briefly ?

231. vMention 3 abnormal findings ?
vMention the most common cause?

232. Band shaped keratopathy

233. Festooned pupil posterior synechia anterior uveitis

234. Iris naevus

236. vAnterior uveitis if not treated probably may
lead to sever complications, what are they ?
- RubeosisIridis

237. Iridotomy

238. Iridectomy

239. Subluxated
lens

240. Subluxated Lens or Aphake
:Tremolous Iris

242. RT CRVO

243. Rt inferior temporal vein occlusion

244. Lt superior temporal vein occlusion

245. Retinal tear surrounded by Argon laser

246. Giant retinal break

247. Rt upper temporal artery occlusion

248. Lt retinal artery occlusion with macula sparing
(cilioretinal artery sparing

249. 5. Parasitic blepharitis
• Pubic louse& its ova(nits).
• Typically affects children with poor hyg.conditions.
• Itching.
Treatment - removal, destruction and delousing

250. Upper lid stye
• .

251. Madarosis ,Tylosis

252. chalesion

253. chalezion

254. stye

255. chalezion

256. Herpes simplex blepharitis vesicles

257. Lower lid ectropion

258. Marcus Gunn jaw-winking syndrome
• Accounts for about 5% of all cases of congenital ptosis
• Retraction or ‘wink’ of ptotic lid in conjunction with
stimulation of ipsilateral pterygoid muscles
Opening of mouth Contralateral movement of jaw

259. Blepharophimosis syndrome (Ptosis -….

260. Pseudomembranous
Pseudomembranes consist of coagulated
exudate adherent to the inflamed
conjunctival
epithelium. Characteristically, they can be
easily peeled off leaving the epithelium
intact.
Causes(1) severe adenoviral infection, (2)
Bacterial conjunctivitis and (3) autoimmune
conjunctivitis.

261. Follicular reaction
• Sub epithelial foci of hyperplastic of
lymphoid tissue with in stroma.
• More prominent in fornices.
• Multiple, discrete, slightly elevated,
lesions encircled by a tiny blood
vessel—small grains of rice.
• Size from 0.5 to 5 mm.
1. Viral.
2. Chlamydial.
3. Parinaud oculoglandular syndrome.
4. Hypersensitivity to topical
medications.

262. Papillae
bacterial conjunctivitis,
allergic conjunctivitis,
chronic blepharitis,
contact lens wear,
superior limbic keratoconjunctivitis floppy
eyelid syndrome. elevated red dots as a result of
the central vascular channel,

263. Papillary reaction
• Hyperplastic conjunctival epithelium.
• Can develop in palpebral conjunctiva (firmly attached)
and limbus.
• Papilla may mask follicles.
• Giant papilla (confluence)
• Non-specific; (less diagnostic)
1. Chronic blephritis.
2. Allergic conjunctivitis.
3. Bacterial conjunctivitis.
4. Contact lens wears.
5. Superior limbic keratoconjunctivitis.
6. Floppy eyelid syndrome.

264. True membranes
True membranes form when the
inflammatory exudate permeates the
superficial layers
of the conjunctival epithelium. Attempts to
remove the membrane may be accompanied
by
tearing of the epithelium and bleeding.
Causes are infections from ß-haemolytic
streptococci and diphtheria.

265. Trachomatus Pannus

266. Limbal vernal
Trantas dotsMucoid nodule

267. Phlycten

268. Limbal phlycten

269. Pinguecula

270. Pterygium

271. Limbal VKC

272. Trachomatous scar

273. PTCs Trachoma

274. Pterygium

275. lagophthalmos
• Definition: inability to close the palpebral fissure

276. Herpes zoster ophthalmicus

277. Lt cherry red spot DD ……

278. Thank You