clinical examination_ ophthalmology

Dr/ M. Abd Ul-Ghaffar (MASS) 2009

یم سبحان اهللا و بحمده سبحان اهللا العظ ٠١٦ ٥٧٠ ١٩١٤: مـــــا س / د

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I- By Charts

تؤدى ھذه اإلختبارات فى حجرة مظلمة - ویعلم قبلھا المریض -

تختبر كل عین لوحدھا -

:Principle of Visual Acuity Charts

If 2-ends of broken ring made Visual Angle > 1minute we could see 2-separate points

passing with Nodal Point & stimulating 2-cones inbetween non-stimulating cone

If Visual Angle < 1minute the 2 points seen as 1-point with closure of broken ring

3-Types : a - Landolt`s chart. b – Snellen`s chart c – Emarah Arabic chart

* Consist of 7-rows of broken rings ( C ) whose openings are in various directions

* Pt. sits at distance of 6m and asked to state direction of opening of C

* Testing each eye separately: . If he saw the last raw VA = 6/6 . If he saw the above one VA = 6/9, then 6/12, 6/18, 6/24, 6/36, 6/60 * When Pt. can`t see at distance of 6m: we move him 1-meter close to chart and . if he saw raw of 60 his VA = 5/60 . If not: move to 4/60, then 3/60, then 2/60, then 1/60 . If not of 1/60, we shift to another method: Counting Fingers

* What do you mean by 6/60 ?! 6 Pt / 60 Normal eye

B – Snellen`s chart C- Emarah Arabic chart Principle: as Landolt`s chart but with letters of different sizes, directions. Value: helpful in determination of uncontrolled astigmatism, because Pt can't see parallel lines of letter E.

With Arabic letters, used in arabic people especially.

A- Landolt`s Chart

قیاس حدة النظر


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II- Counting Fingers (CF)

III- Hand Movement (HM)

IV- Perception of Light (PL)

. * Done when Pt can't see charts at 1-meter * Ask Pt to count your fingers * Start by 75cm, if Pt can count fingers VA = CF 75cm * If not: to CF 50cm, then CF 25cm

- Done when Pt. can’t count fingers at all. - Teach Pt that your hand is now moving, and then stop movement and tell him it is now stopped - then Test Pt, if he can detect VA = HM

Done when Pt can't see HM

At 1st Teach Pt.: this is Light and this is Darkness

Then ask him: . if could perceive light VA = PL . if not VA = no PL / blind

(Testing of Retinal Periphery)

Time: done if vision < CF 50cm.

How: * At 1st, Do PL because if no PL no Light projection occurs.

* To do test: - The eye is fixed in 1ry position - Teach Pt.: by telling him direction of light and then ask him about direction of light or ask him to catch it.

Importance: Testing of retinal periphery when we can't see with Ophthalmoscope because

of total cataract or any opacity in media (to be sure of good retinal function before doing cataract extraction, …)

V- Light Projection Test


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Center of retina (Testing of function of Cones)

* Form sense: determination of shapes, figures via testing visual acuity. * Colour sense: - Ishihara colour book. - Wool threads. - Spectroscope * Visual Acuity * Maddox rod * ERG ect…

(For testing Visual Field)

Time: Vision must be > CF 50 cm

How: To do the test

- Sit in front of Pt. - Ask Pt. to close Lt eye and cover your Rt eye - your uncovered eyes are fixing to each other - Distance between you and Pt. is at least 1 meter

- With your index finger at distance 50-60 cm between you and Pt.,moving from outside inside till Pt see it - Begin from: Up Nasal side Down Temporal - Compare the sites at when Pt. can see your finger in all directions with your own field.

Other accurate methods: - Arc perimeter peripheral field changes. - Bjerrum screen central field changes. - Goldman perimeter both fields

قیاس مجال الرؤیة


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How: To do the test

1- Apply source of light to one eye and prevent light to reach the other eye by putting your hand vertically over bridge of nose

2- .Watch Direct light reflex in the same eye normally miosis occurs as long as the light is present.

.Watch Indirect light reflex in the other eye.

Pathway: - Stimulus: Light - Receptors: Visual receptors (Rods – Cones) - Afferent: ON (2nd n) Optic chiasma (1st decussation: Nasal fibers cross to reach optic tract of opposite

side & Temporal fibers pass directly into optic tract of same side) Optic tract (2nd decussation: Fibers leave optic tract at post 1/3 to relay in Pre-tectal nucleus of mid-brain both EW nuclei.

- Center: Edinger Westphal nucleus. - Efferent: Oculomotor (3rd n) Ciliary ganglion Sphincter pupillae

- Effector: Sphincter Pupillae muscle. - Response: reflex bilateral Miosis.

NB: Consensual Light reflex: d2 Crossing of fibers in Chiasma, Midbrain

نور للعین


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Principle: ( When Near object is viewed 3-related reflexes ) - Convergence: contraction of 2-MR muscles. - Miosis: contraction of 2-Sphincter pupillae muscles. - Accommodation: contraction of 2-Ciliary muscles.

Pathway: - Stimulus : Blurring image - Receptors: Visual receptors ( Rods – Cones ) - Afferent: ON Optic chiasma (decussation: Nasal fibers cross )

Optic tract LGB Optic Radiation Occipital Cortex Frontal Cortex Internal Capsule Edinger Westphal nucleus.

- Center: Edinger Westphal nucleus . - Efferent: Oculomotor (3rd n) Ciliary ganglion Sphincter pupillae m.

- Effector: 2-MR muscles & 2-Sphincter Pupillae muscle & 2-Ciliary muscles - Response: reflex bilateral Convergence + Miosis + Accommodation


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Site: upper antero temporal part of orbit

Normally: not palpable

How: To do the test (Rt little finger to Rt eye)

- Ask patient to look down, nasally - Introduce your little finger with its bulls facing upward - Press between Upper lateral part of bony orbit & Globe: (Back Lat. Up) (your finger opposite eye direction)

* If Lacrimal Gland was palpable that means it is enlarged.

* What are causes of enlarged palpable lacrimal gland ?! - Tumors of lacrimal gland (mixed cell tumour) - Dacryoadenitis

اجعل المریض ینظر لتحت ولجوة-

By little finger: تلحظ جزء ظھر أمامك فلیشي أحمر وللخارجألعلي )اللي فوق الغدة( شد الجفن -

رؤیة الغدة الدمعیة

الدمعیةحس الغدة


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Site: Lacrimal Fossa in medial lower part of orbit, below MPL

How: To do the test (Rt little finger to Lt eye)

- Push lateral lid margin down and lateral till feeling MPL medially - Press with your little finger under MPL: (back med.) to expose lower punctum and notice any regurgitation

. If no regurgitation = -ve Regurge test . If any regurgitation (purulent, serous, …) = +ve Regurge test

Q- What are the lesions in lacrinial sac with -ve regurgitation ?! - Acute dacryocystitis: d2 congestion of epithelium of canaliculi which prevent regurgitation from lacrimal sac, being very tender.

- Encysted mucocele: due to fibrous closure of the passage with accumulation of mucus inside.

- Lacrimal Fistula: because any discharge will pass first to opening of skin. Q- How to test Patency of lacrimal passages ?! 1- Fluorescein test: drop in conjunctival sac + cotton pellet under inferior turbinate of nose

2- Syringing e saline 3- Probing 4- Dacryocystography (plain X-ray + lipidol) 5- ENT examination

Importance: detection of state of OO muscle & its 7th nerve

How: To do the test

1- Ask Person to close his eye firmly 2- Insert your thumb and index fingers, try to open Person`s eye gently:- . if difficulty opened = intact of OO, 7th . if opened easily = palsy of OO or 7th

دمعیة الSacحس

7th n intact: غمض عینیك قوي

Regurgitation Test


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Importance: Assessment of Power or Function of LPS (Thumb test) as in Ptosis Normally: upper lid is elevated by 3 -muscles: LPS, MM, Frontalis

- LPS = 3rd n. - Frontalis = 7th n. - MM = sympathetic n. plexus (C1, C2)

How: To do the test - Correct Head position → Ask Pt to look down imummax Fix brow against superior orbital margin by thumb (الدكتور ) ?! → Ask Pt to look up imummax Measure amount of elevation of UL margin (in mm): - Degrees:

- If Pt could not elevate his lid Ptosis (complete absence of levator action)

Excellent Good Fair Poor

> 10 mm 7: 10 mm 4 : 6 mrn mm3 <

الجفنقوة رافعة


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Importance: - FB impacted in sulcus subtarsalis.

- PTDs, PTCs, Arlet`s line of Trachoma - Follicles and Papillae. - Membrane either true or pseudo - Presence of Hge

How: To do the test

1- Ask Pt. to look down 2- Evert Lid by: . Glass rod with thumb + index finger, or Only . Your thumb + index finger 3- Index is put behind tarsus 4- Thumb holds up lashes or lid margin (the best) pull lid Forward evert it over your index finger, acting as axis. Press with your index on tarsus, being hard lid can’t be everted إوعى * Normally: in Egyptians PTDs, PTCs and Arlet`s line: being line of fibrosis along sulcus subtarsalis 2- mm from lid margin

Q- Why Arlet’s line is present in sulcus subtarsalis: Because it is grooved, rich in BVs Q- What is the difference () papillae of spring catarrh and trachoma

Papillae of Spring Catarrh Papillae of Trachoma Incidence Gender Season Symptoms Papillae - Appearance - Size - Color - Upper fornix Discharge

- ♀ > ♂ - ↑ in summer and spring ..Itching -Cobble stone -Larger -Bluish white -Free ..Roby, rich in eosinophils

- ♀ = ♂ - any season ..Heaviness of lid -Top is rounded -Smaller -Red -Involved ..Watery, inclusion bodies

(no eosinophils)

قلب الجفن


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Normal IOP: 10-22 mmHg above atmospheric pressure.

How: To do the test

A- Digital Palpation method - Via 2-index fingers - We ask Pt. to look down (not to close his eyes, because contraction of muscle will ↑ its tone false ↑ in IOP)

- Feel tension above tarsus (behind it) via pressing with finger and receiving by other finger - Compare tension in both eyes before recording - Finally we say: (Hard or Firm or Soft) Tension NB: - Don’t feel tension over tarsus being fibrous, hard.

- Here we measure Tension and not Pressure, measured via introducing needle of apparatus in the eye

Digital method is not accurate rough, so we may use: B- Schiotz indentation tonometer

* Schiotz has the following disadvantages: - With instrumental errors - Observer error - May be changed by changing ocular rigidity.

* Schiotz has the followIng advatnagcs: - Simple - Cheap - Portable

C- Goldman applanation tonometer

* Advantages of Applanation: - No error. - No change with ocular rigidity.

D- Tonopen

E- Airpuff Tonometer

N.B.:

A) IOP > 22mmHg is suspicious to be glaucomatous, so we do provocative tests:

1) Closed angle glaucoma: - Dark room - Mydriatic

2) Open angle glaucoma: - Priscol. - Water drinking test

B) Above 26 mmHg: Patient is sure glaucomatous

قیاس ضغط العین


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.

How: To do the test - The Material used and Hands of the doctor: should be clean and sterile - Hold piece of cotton under Lower Lid (LL) of Pt. and pull LL to expose inferior fornix.

- Ask Pt. to look up - Apply the drops in fornix, and avoid touching the eye or lash for fear of infection transmission to another person or to your eye.

* In case of suspected corneal ulcer apply Fluorescein ED

Q- Uses of Fluorescein in Ophthalmology: 1- Lacrimal: - Test patency of NLD - Dry eye syndrome - Investigation of a case of epiphora 2- Cornea: Detection of corneal ulcer, corneal fistula, FB. 3- Retina: FA of DR, CRVO, CRAO N.B.: - Fluorescein may carry the danger of pseudomonas infection w prefer it, so be aware of this point


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One of the protective mechanisms to the eye.

How: To do the test (أوال شتت انتباھھ وال تجعلھ یرى حركة یدك ) - Twist end of piece of cotton to be a thread - Ask Pt. to look medially and with cotton thread touch cornea without touching lashes.

Pathway: - Stimulus: thread of cotton.

- Receptors: touch receptors of cornea. - Afferent: 2-long ciliary nerves ( nasociliary n ophthalmic n 5th nerve )

- Center: area 18/occipital cortex. - Efferent: 7th nerve - Effector: Orbicularis Oculi muscle - Response: bilateral reflex closure of eye lids

Types of Blinking: - Spontaneous: Basal ganglia - Reflex: occipital cortex 18 - Voluntary: frontal cortex 8 یغمز

Q- What are Causes of diminished or lost corneal reflex: A- Factors due to affection of receptors hyposethia - Corneal scarring because fibrous tissue is insensitive.

- Keratitis: herpitic keratitis (herpes simplex, herpes zoster) - Leprosy - Glaucoma (absolute, acute congestive) - Local anaesthesia of ED B- Factors due to affection of afferent and efferent nerves - 5th nerve injury or trauma - 7th nerve injury via tumors in pons, trauma, vascular lesion, Bell's palsy

C- Factors due to lesion in the effector organ- Due to palsy of orbicularis oculi muscle

Blinking Reflex


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Definition: abnormal ocular deviation so that the 2-visual axes are not directed towards fixation object, one of them being deviated.

Clinical classification of ąSquint:- رؤف النفیس / التقسیمة من أدھذه A) Latent (Heterophoria):- مخفى 1- Eso-phoria 2- Exo-phoria 3- Hypo-phoria 4- Hyper-phoria 5- In-Cyclo-phoria 6- Ex-Cyclo-phoria

B) Manifest :- ظاھر 1- False /Apparent / Pseudostrabismus بذاـ ك 2- True squint: - صادق * Incomitant (Paralytic) * Concomitant (Hetero-tropia) - Vertical: (Hypo-tropia – Hyper-tropia) - Horizontal: (Eso-tropia – Exo-tropia) - Mixed: (horizontal + vertical squint)

Importance: rough method to measure Angle of Squint.

How: To do the test

1- Pt. is asked to look to source of light put at 50cm from him 2- The corneal reflection of light is noticed: . Normally, point of light at Center of both Pupils . if at Pupillary border = 10 -15 angle . if half-way () Pupillary border and Limbus = 20 – 25 . if at Limbus = 40 – 45 . if on the Sclera = 7 are added to each 1mm away from limbus. Measurement of Angle of Squint by: - Corneal reflection test - Arc Perimeter - Synoptophore


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The movement of globe is controlled by 6-EOMs: * 4-Recti: medial, lateral, superior, inferior. * 2-Oblique: superior, inferior.

Actions of EOMs →

3-main Positions of the eye (9-Gazes/directions)

A- Primary position B- Secondary positions C-Tertiary positions

Cardinal Directions of the Eye: At each direction:

- only one muscle moves eye ball - So any defect in this direction = defect in its muscle To test Ocular Motility (2 movements),

1) Pt is asked to follow finger put at 50cm from his eye and move in all directions of gauze Ocular movements are normal in latent and concomitant squint. Limitation of movement is found in paralytic squint. 2) Done uniocular (Duction) then binocular (Version) by 2-methods: A- Following movement. = F / O, 18 B- Order movement = O / F, 8 * Any defect in any direction = defect in muscle or its nerve supply So eye is squinting in opposite direction

* What are the Muscles acting when looking up ?! (5- muscles) = 2-in eye: SR – IO & 3-in lid : LPS – MM – Frontalis

* How to test the function of SR ?! By asking Pt. to Look up + out at the same time

* What is the muscle acting during reading ?! SO muscle

3 2 3

2 1 2

3 2 3


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مخفىال (to diagnosis Latent Squint ) ) وأنت ترید أن تعرف ھل عنده حول مخفى أم ال ‘ل ومریض داخلك وغیر ظاھر فى عینھ ح( یؤدى ھذا اإلختبار لـ - غطى أى عین ثم راقب حركتھا بعد إزالة الغطاء-

- Make Pt. to fix on pencil_torch putting at 50cm - Cover one eye - Cover is rapidly removed - Latent squint is detected, if this eye is noticed to move to take fixation - This mains that this eye was squinting under Cover

( to diagnosis Concomitant Squint )

یؤدى ھذا اإلختبار لـ -)وأنت ترید أن تعرف ھل ھذا الحول فى عین واحدة أم في اإلثنین ‘ ل ومریض داخلك و ظاھر فى عینھ ح(

: عمل أوال -Paralytic squint ولیس Concomitant squint للتأكد من أنھ Ocular motility test

...اجعل العین المحولة تثبت على غطى العین السلیمة ، ثم - - عند إزالة الغطاء: راقب العین المحولة المكشوفة ألى حركة :

Unilateral Concomitant Squint = إذا احولت العین مرة أخرى. Alternating Concomitant Squint = إذا ثبتت ھذه العین واحولت العین المغطاة .

Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 سبحان اهللا وبحمده سبحان اهللا العظیم

كیف تعرفھا الحالة

1- Chalazion كیس دھنى عنده من زمان

2- Stye دمل طالع منھ شعره

3- Squamous Blepharitis +حافة الجفن حمراء + قشر أبیض بین الرموش

نھ من الھرشبیقطع جف: ولو سألت المریض

4- Ptosis الجفن العلوى مرتخ

5- Entropion جفن مقلوب لجوه

6- Ectropion جفن مقلوب لبره

7- Lagophthalmos مش قادر یقفل عینھ

8- Lid Retraction إنت شایف بیاض من فوق القرنیة

9- Rubbing Lashes ى العینأقل من أربعة رموش یحكون ف

10- Distichiasis صف زائد من الرموش یحك فى العین

11- Trichiasis أكثرمن أربعة رموش یحكون فى العین

12- Poliosis أبو رموش بیضاء

13- Madarosis الالال رموش

14- Xanthelasma رجل عجوز(حب أصفر على الجلد (

15- Dermatochalasis رجل عجوز(جلد مترھل و زائد من الجفن العلوى (

16- Papilloma حالة ألول مرة تنزل في إمتحان اإلكلینیكى العام الماضى

الحالة كیف تعرفھا

1ry or 2ry (Recurrent): إما- ظفرة ملتحمة شكلھا مثلث رأسھ إلى القرنیة- ل المریضأ إس: من اآلخر

1- Pterygium

Pseudopterygium -2 تحتھ .. ملتحمة ماسكة فى عتامة علي القرنیة یمكنك إمرار Pinguecula -3 لیس غشاء مثل الظفرة ، مثلث أصفر قاعدتھ إلى القرنیة

Diffuse Bleb (SST) -4 لو سألت المریض عن عملیة میة زركھ، حاجھ بزه Subconjunctival -5 ... یمیزماإذاالسبب خبطة للعین أم للرأس- ایح تحت الملتحمة دم س-

Hge Symblepharon -6 الجفن ماسك فى العین

Conjunctival -7 سیئة فى العین Naevus

Red Conjunctiva -8 ....، إلتھاب ، إرھاق Keratitis, Iridocyclitis, Glaucoma ←Limbus 9 أوعیة حمرة و واضحة قوى حول الـ- Ciliary injection

Conjunctivitis ←Fornices 10 أوعیة حمرة و واضحة قوى خاصة فى الـ- Conjunctival injection

الحالة كیف تعرفھا

Pannus Siccus -1 ھالل أبیض یحیط القرنیة من فوق Arcus Senilis -2 )العجوز(ة حلقة عتامة تحیط القرنی

Nebula -3 إال إذا اقتربت منھا ونورت من الجانبالتراھاسحابة التى تجد معھا النینى غیر منتظم LA & التى ھى عتامة فقط LNA : إما- عتامة بضاء قویة-

4- Leucoma

:لو نظر ألسفل : قرنیة قمعیة مخروطیة مبظبظة شفافة Angulation of LL on looking down ←Munson`s Sign

5- Keratoconus

Keratectasia -6 قرنیة معتمة و مبظبظة بس iris 7- Ant. Staphylomaمبطنة بـ + قرنیة معتمة و مبظبظة

Strabismus/ Squint بالعربي فى مذكرة مشروح *

(Clinical examination)


1- Hypopyon Pus in AC

2-Hyphaema Blood in AC

3- AC IOL In case of ICCE

Anterior Chamber


1- Atrophia Bulbi

عین عمیاء صغیرة منكمشة داخل - واضحة المعالم األوربیت

2- Phthisis Bulbi

- عین بایظة ، زى لحمة متحركة ، غیر واضحة المعالم

Orbit

*Dacryocystitis: - epiphora - red swelling Lac. Sac - +ve Regurge Test - ttt: DCR

Lacrimal Apparatus

Eye Lid

Conjunctiva

aCorne

Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 سبحان اهللا وبحمده سبحان اهللا العظیم

Iris

Cataract/ Lens


1- Peripheral iridectomy Part of iris is removed (near its root)- فوق

-Pupil remains round 2- Sector iridectomy

(Key-hole)

-Part of iris is removed

(from:pupil to:ciliary border)

3- Visual iridectomy -Small part of iris is removed: (Down+ In)

(near pupil,but not reach Ciliary border)

4- Coloboma of iris اسألھ ھل ولد بھا-

- defect in iris - bilateral, down + in

5- Iridodialysis - D-shaped pupil

- lost peripheral area of iris 6- Iridodoneisis قزحیة تھتز (tremulous iris) 7- Patches of iris atrophy أجزاء میتھ مبیضھ على سطح القزحیة - 8- Anterior Synechia -iris + cornea:

)النینى غیر منتظم( قزحیة ماسكة فى ظھر قرنیة شفافة 9- Posterior Synechia -iris + lens -قزحیة ماسكة فى العدسة


1- Normal Pupil

RRRCE = regular, reactive, round,

central, equal on both sides

2- Dilated fixed pupil تجمیعة مھمة جداااااااا فى الشفوى

یتحك علیك ویعطى الحاج قطرة توسیع -

- CRAO

- OA

- Absolute glaucoma

- 3rd nerve palsy

3- An iso coria Un equal 2-pupils

4- Drawn up Pupil

-Pupil isn`t

(central , round)

-Iris tissue is present all

around pupil

5- Irregular Pupil

-Leucoma Adherent

-Ant, Post Synechia

الحالة كیف تعرفھا Developmental - مولود بھا

بط اتخ - Traumatic

(Blunt Tr. & Penetrating Tr.)

اسألھ عن أمراض یشتكى منھا مثل السكر والضغط-

سنھ٥٠ سنھ تحت الـ - ما اتخبط -

- Complicated

Incipient مثلثات فى االطرافIris shadow Immature + العدسة فیھاعتامة

Mature - العدسة كلھا عتامة Intumescent العدسة منفوخة و بتلمع- عتامة مثل الصدفة أو قشر سمك-

العدسة منكمشة و منقطھ أبیض و أصفر-

ة تحت لبن و النواة البنیة غارق-

Hyper mature: - Shrunken - Morgagnian

- Senile Cortical سنة٥٠ حاج كبیر السن فوق الـ -

وغیرمولود بھا ، والعنده مرض، اتخبط ما-

- brownish yellow opacity at Center of lens Senile Nuclear - اسأل المریض ھل نظره بیتأثر بالنھار أكثر-

Aphakia - صورة واحدة فقط على القرنیة- عمل عملیة میة بیضھ وما زرعش : اسألھ- ع عدسةعمل عملیة میة بیضھ وزر-

- العدسة كلھا امامك

AC IOL

عمل عملیة میة بیضھ وزرع عدسة -

عینھ بتسرج وبتبرق: مح حركة النور-

PC IOL

- Pseudophakia

عمل عملیة میة بیضھ وردت علیھ - :Pupil عتامة فى-

- After Cataract

Pupil

clinical examination_ ophthalmology

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