Clinical examination of eyes By Pandian M
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This document provides guidance on clinically examining the eyes. It outlines the key steps which include inspecting the eyelids, lashes, lacrimal apparatus, conjunctiva, cornea, sclera, anterior chamber, iris, pupils, lens, and fundus. For each structure, the examiner is instructed to observe for any abnormalities in color, shape, size, discharge, opacity, or other features and compare across both eyes. Palpation of the eyeball is also described to assess tension. The goal is to systematically examine each individual part of the eye and observe any abnormalities.
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2. It also summarizes causes of trabecular pigmentation, associations of vortex keratopathy, indications for vitrectomy, and causes of choroidal neovascular membranes.
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1. 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, symblephara, ankyloblepharon and forniceal shortening are often more obvious on gross inspection before beginning the slit lamp examination.
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Blepharitis,
Ectropion / entropion / punctum
Madarosis / hypertrichiasis
Scarring from HZO / pigment changes
3. Conjunctiva/Sclera
Ask the patient 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
4. Cornea
Always mark the visual axis.
Always draw a cross-section with corneal epithelium / stroma / endothelium, iris and lens (Figure 1.1.1). It is important to document the level, size, shape and location of any corneal lesion.
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
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
In addition, look at 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)
Stroma: Dystrophies, stromal oedema, vessels (superficial or deep?), prominent corneal nerves
Endothelium: Guttata, pigment dispersion, keratic precipitates (KP), Descemet’s membrane folds
The presence of 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).
If an ocular surface mass is present (e.g. Ocular surface squamous neoplasia), you must exclude orbital invasion. Check for:
Lymphadenopathy
Corneal sensation
Ophthalmoplegia
Intraocular examination including gonioscopy for angle involvement
5. 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
Fundus examination
The document provides details on performing a fundus examination, including:
- The history of the ophthalmoscope and its modern use
- Preparation steps like pupil dilation
- Proper positioning and examination technique
- What to expect to see in a normal fundus exam, including the optic disc, blood vessels, macula
- Common abnormalities that may be observed, such as cotton wool spots, exudates, hemorrhages
- Conditions like glaucoma, hypertensive retinopathy, and diabetic retinopathy that can be assessed during the exam
EYE Assessment
This document provides guidance on performing a comprehensive eye examination, including:
- Testing visual acuity using a Snellen chart from 20 feet and reducing distance if needed.
- Examining the external eye structures like eyelids, sclera, conjunctiva, pupils and extraocular eye movements.
- Evaluating the cranial nerves that control eye movement by having the patient follow an object.
- Using diagnostic tools like an ophthalmoscope, slit lamp, color vision tests, Amsler grid, OCT and color fundus photography.
The examination aims to gather a thorough ocular history and inspect the eye to assist in diagnosing any eye conditions.
Assessment 191008083120
This document provides information on performing a comprehensive eye examination, including:
- Assessing visual acuity using a Snellen chart
- Examining the external structures of the eye
- Testing eye movements and cranial nerve function
- Performing diagnostic tests like ophthalmoscopy, slit lamp examination, and tonometry
- Evaluating color vision, the macula, retinal blood vessels, and intraocular pressure
The goal is to gather all relevant information to assist in diagnosing any ocular conditions.
The eye
The document provides information on techniques for examining the eye, including:
1. Visual acuity is tested using a Snellen eye chart from 20 feet.
2. Visual fields are assessed using confrontation tests like finger wiggling.
3. The optic disc, retina, blood vessels and macula are examined using an ophthalmoscope.
STRABISMUS EXAMINATION.pptx.............
Eye Movements Examination
Examination Structure
Sit on the right of the patient, your eyes and the patient’s eyes should be at the same level
Speak whilst examining
Ask children their age
Look around the room for clues – spectacles, parents (for inherited syndromes)
1. Visual Acuity (Best Corrected)
The worse eye is usually the affected one (may be amblyopic)
2. Spectacles
It is easiest to estimate the script of spectacles by comparing the image of a line viewed through the lens and just around it. A distance line such as a doorway is perfect for this purpose.
Hand Neutralise
Minus lens → “With” movement
Plus lens → “Against” movement
Astigmatism
Ground in Prism
The image of the line through the lens has a fixed deviation away from the image of the line just around it. This cannot be compensated by moving the lens. The apex of the prism points towards the deviation.
Fresnel Prism
Method for easy check: turn spectacles side-on
BO (CNVI palsy), BD (CNIV palsy on affected eye)
3. Inspection
Have the patient fixate on a distant target- choose one line above their visual acuity
Only comment on a strabismus if it is obvious (say “there appears to be an exo or eso deviation” in case the patient has a dragged macula and there is no tropia)
1. Abnormal Head Posture (AHP)
Ask patient to “Please sit up straight” and stand back to inspect
Face turn? In direction of action of paretic muscle
Chin up / down? Up in elevator paresis, Down in depressor paresis
Correct any AHP before cover tests (check for neck pathology)
2. ± Corneal Light Reflexes (Hirschberg)
Shine a pen torch into the patient’s eyes and inspect the corneal reflexes. In patients with straight eyes, they should be symmetrical and lie over the same point on the cornea. In patients with strabismus, the corneal reflex of the fixing eye will lie centrally within the pupil, and the other will be displaced (1mm of corneal decentration = 15 Δ strabismus, Pupil margin = 30 Δ, Limbus = 90 Δ). Be aware that tropias can only be definitively diagnosed with cover testing. The Hirschberg test becomes more important when vision is poor (e.g. < 6 / 60 in either eye) and cover-testing is not possible.
3. Ptosis (CNIII palsy)
4. Pupils (Anisocoria) (CNIII palsy)
5. Globe Position
Proptosis (axial vs. non-axial)
6. Other
Nystagmus, facial asymmetry, hearing aids, scars (conjunctiva- squint surgery)
7. Ask Yourself
“Could this be TED?”- proptosis, chemosis, injection, lid retraction
4. Cover-Testing
Ensure the patient can fixate “Tell me if I block your view”
If VA <6 / 60 can’t do cover! → Perform Hirschberg (corneal light reflexes) and / or Krimsky (corneal light reflexes through prism placed over the fixing eye) tests.
The patient should wear their distance (& near) spectacles (unless they have prisms!)
This helps the patient if they can’t fixate on a target uncorrected
It is crucial in accommodative esotropia to test with and without spectacles
Cover for tropia (manifest)
Uncover for phoria (latent)
Eye and ear assessment
This document provides information on performing a physical assessment of the eyes and ears. It discusses important landmarks to inspect in the eyes including the eyelids, eyebrows, lacrimal apparatus and positioning. Common eye conditions like blepharitis, chalazion, styes, ptosis, and nystagmus are described. Assessment techniques for the eyes include checking visual acuity, extraocular muscle function, visual fields, pupillary response, and ophthalmoscopy. For the ears, inspection, otoscopy and tests of auditory function like the Weber test and Rinne test are outlined. Common causes and presentations of conductive and sensorineural hearing loss are also summarized.
eyeandearassessment and its diagnosis and treatment
This document provides information on performing a physical assessment of the eyes and ears. It discusses important landmarks to inspect in the eyes including the eyelids, eyebrows, lacrimal apparatus and positioning. Common eye conditions like blepharitis, chalazion, styes, ptosis, and nystagmus are described. Assessment techniques for the eyes include checking visual acuity, extraocular muscle function, visual fields, pupillary response, and ophthalmoscopy. For the ears, inspection, otoscopy and tests of auditory acuity like the Weber and Rinne tests are outlined. Common causes and presentations of conductive and sensorineural hearing loss are summarized. Proper techniques for examining the eyes and ears
Basic Eye Exam RESOURCE.pdf
This document provides an overview of the basic ophthalmologic examination. It discusses evaluating visual acuity, visual fields, ocular motility, external examination of adnexa and globe, tonometry, and funduscopy. The examination is aimed at assessing visual function, appearance of the eye, sensation, and directly viewing the retina and optic nerve through dilation to check for abnormalities. Findings are recorded using standardized notation to document acuity, motility, tonometry measurements, presence or absence of lesions, and details of the retina and optic disc.
Ophthalmoscopic slides
This document provides instructions for performing a direct ophthalmoscopy exam, including: examining the red reflex and funduscopic view of the optic disc, vessels, macula and any pathology; using lenses and filters to better visualize structures; documenting findings; and ensuring patient comfort and consent throughout the process. Key steps involve darkening the room, inserting dilating eye drops if needed, positioning the patient, and systematically examining both eyes with an ophthalmoscope to evaluate internal eye structures and diagnose any abnormalities.
Direct ophthalmoscopy
normal fundus , the retina how it works & how it is visualised is described here.
the procedure of direct ophthalmoscopy how the image is seen.
Abnormalities of retina how are they seen.
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Clinical examination of eyes By Pandian M
- 1. CLINICAL EXAMINATION OF EYES PANDIAN DEPT OF PHYSIOLOGY DYPMCKOP
- 2. SLO • SYMPTOMS • MATERIAL • EXAMINATION • INSPECTION • OBSERVATIONS • EXAMINATION OF DIFFERENT PARTS • PALPATION
- 3. University of Jordan 3
- 4. University of Jordan 4
- 6. SYMPTOMS •Difficulty in seeing or reading, headache, pain in or around eyes, redness of eyes, any discharge from the eyes, etc.
- 8. •MATERIAL •Pentorch •EXAMINATION : •Subject must be seated in good light. •Examine both eyes systematically and separately.
- 9. INSPECTION 1. Any obvious abnormality : note for ptosis, exophthalmos, nystagmus or abnormal position of head & squint.
- 10. OBSERVATIONS Inspection 1. Observe for ptosis, exophthalmos, nystagmus, squint. Name, Age, Sex, Date & Time.
- 15. Squint
- 16. 2. EXAMINATION OF DIFFERENT PARTS : i) eyelids : see thickness, colour and position, size of the palpebral fissure and condition of margins.
- 17. EYELIDS A. Rate of blinking --- B. Gap between upper eyelid and cornea : present / absent C. Margin : thickening / swelling / discharge / normal D. Eyelashes : direction / loss E. Palpebral fissure : wide / narrow / medium Compare the two eyes : equal / unequal
- 20. ii) eyelashes : see condition and direction of the eyelashes,
- 23. 3. LACRIMAL APPARATUS A. Can a part of it be located by inspection or palpation? B. Punctum : discharge : nil / watery / pus Lacrimal sac : it is situated at the medial angle of the eye. See whether there is any swelling in the region. See position and size of lacrimal puncta.
- 24. Normal eye
- 27. • iv) Conjunctiva : bulbar portion is easily seen. • To expose the palpebral conjunctiva of lower eyelid, place the thumb near the margin of the eyelid and press downwards while the subject looks upwards. • The palpebral conjunctiva of upper eyelid is exposed by everting it with the hand while the subject looks downwards. • Examine both conjunctiva for colour and look for haemorrhagic spots. • Also look for shininess, discharge, abnormal vascularity, any foreign bodies etc.
- 28. CONJUNCTIVA A. Palpebral. Angry red / highly vascular / pale/smooth and pink. Discharge : present / absent B. Bulbar conjunctiva : vascular / smooth and shiny. Folds of conjunctiva (pterygium): present / absent discharge : present / absent
- 30. Discharge
- 31. Bulbar conjunctiva : vascular / smooth and shiny.
- 33. v) Cornea : see for abrasion, ulceration, vascularization, opacities or foreign bodies. •The corneal reflection derived from the window bars gives information about its curvature and smoothness.
- 34. Cornea A. Window bar reflection : smooth / distorted B. Opacity : absent / present If present, its size, shape situation C. Vascularization : reaching upto cornea / falling short of cornea.
- 35. N
- 36. Opacity
- 39. 6. SCLERA A. Colour: bluish, white, muddy, any other description B. Haemorrhagic spots : present / absent sclera : note the colour and look for haemorrhagic spots.
- 41. Bluish Muddy
- 43. vii) Anterior chamber: See the depth. Look for any deposits in it and presence of pus, blood etc. •Normal / shallow / deep •Pus or blood : present / absent
- 45. Pus or blood : present / absent
- 46. 8. IRIS Colour of pigments : •Exudation : present / absent •Adhesions : present / absent viii) Iris : See colour, smoothness and thickness. See if it is steady or tremulous.
- 47. Pigments in Iris
- 48. Exudation (Hypopyon) Adhesions (iris and lens)
- 50. 9. PUPILS •Fixed / oscillatory (hippus). •Shape : regular / irregular / oval •(Reaction to the light will be studied under visual reflexes). ix) pupil : pupil is noted with regards to size, shape and position, and also its reaction to light,
- 55. 10. LENS • Present / absent. If present: transparent / translucent / opaque. x) lens : only central part of the anterior surface is seen. See it for Its transparency,
- 56. 11. FUNDUS • THIS IS EXAMINED BY OPHTHALMOSCOPE. Normal Retina xi) fundus : it is to be seen with ophthalmoscope.
- 57. PALPATION •Eyeball tension : to ascertain it, direct the subject to look downward. •Palpate the eyeball gently by means of the two index fingers placed upon the upper eyelid, •The middle finger being supported on the patient's forehead. Examine the other eye as well.
- 58. PALPATION • Eye ball tension : normal / increased / decreased compare • The two eyes compare with your own
- 60. REFERENCE •HUTCHINSON’S CLINICAL METHODS •A.K. JAIN, C.L. GHAI, G.K. PAL •GOOGLE IMAGE FOR PICTURES •NET SOURCE
- 61. THANK YOU
Editor's Notes
- Foreign body called as FB
- Limbus
- Exudation--Hypopyon is a medical condition involving inflammatory cells in the anterior chamber of the eye. It is a leukocytic exudate, seen in the anterior chamber, usually accompanied by redness of the conjunctiva and the underlying episclera
- Pupillary hippus, also known as pupillary athetosis, is spasmodic, rhythmic, but regular dilating and contracting pupillary movements between the sphincter and dilator muscles