Examination of Eye 1. Examination of Anterior Segment Examination of Posterior Segment 2

Examination of EyeExamination of Eye

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Examination of Anterior SegmentExamination of Anterior Segment

Examination of Posterior Segment Examination of Posterior Segment

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Examination of Anterior Segment of EyeExamination of Anterior Segment of Eye

1.1. Examination of VisionExamination of Vision

Assessment of visual functionAssessment of visual function• Forms of visual perception are form Forms of visual perception are form

sense , the field of vision, the light sense sense , the field of vision, the light sense and the colour sense, these senses are and the colour sense, these senses are checked with checked with

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Examination of EyeExamination of Eye

• Visual AcuityVisual Acuity• Visual field examination with confrontation test, Visual field examination with confrontation test,

perimetry (kinetic and static)perimetry (kinetic and static)• Dark adaptation – measurement of least Dark adaptation – measurement of least

luminance required to produce a visual luminance required to produce a visual sensation sensation

• Contrast sensitivity – is measurement of the Contrast sensitivity – is measurement of the smallest distinguishable contrast ,it is smallest distinguishable contrast ,it is assessment of quality of visionassessment of quality of vision

• Colour vision –with lantern test (Edridge green Colour vision –with lantern test (Edridge green lantern) and Isochromatic charts lantern) and Isochromatic charts

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Visual AcuityVisual Acuity

• Definition-Definition-It is defined as the measure of the smallest It is defined as the measure of the smallest retinal image which can be appreciated with retinal image which can be appreciated with reference to its shape and size .it is actually reference to its shape and size .it is actually measure of form sense.measure of form sense.Subjective examination of the function of eye Subjective examination of the function of eye

• Central or direct vision Central or direct vision • Distance visionDistance vision with Snellen test type with Snellen test type • Near visionNear vision with Snellen test type or Jaeger’s with Snellen test type or Jaeger’s

test type test type

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Visual AcuityVisual Acuity

The principal of assessment is The principal of assessment is measurement of spatial resolution of the measurement of spatial resolution of the eye i.e. an estimation of ability of eye to eye i.e. an estimation of ability of eye to discriminate between two points. discriminate between two points.

DISTANCE VISION DISTANCE VISION

Two distance point can be visible as separate Two distance point can be visible as separate only when they subtend an angle of 1 minute only when they subtend an angle of 1 minute at the nodal point of eye. at the nodal point of eye.

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Snellen chartSnellen chart

Principle Principle • Each individual letter subtends an angle of 5 Each individual letter subtends an angle of 5

minutes and each component of letter subtends minutes and each component of letter subtends an angle of 1 minute at the nodal point of eye an angle of 1 minute at the nodal point of eye from the distance in meters written as numerical.from the distance in meters written as numerical.

• Snellen chart is having different number of Snellen chart is having different number of letters in different rows and the letter at top line letters in different rows and the letter at top line should be read clearly at distance of 60 m. should be read clearly at distance of 60 m. similarly the letters at subsequent lines as are similarly the letters at subsequent lines as are read at 36, 24,18,12,9,6,5mts respectively read at 36, 24,18,12,9,6,5mts respectively

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Snellen ChartSnellen Chart

Snellen ChartSnellen Chart

Trial FrameTrial Frame

Occluder and Pin HoleOccluder and Pin Hole

Snellen chartSnellen chart

Numerical convention is used for recording Numerical convention is used for recording visual acuity. In fraction, the numerator is visual acuity. In fraction, the numerator is the distance at which the patient is sitting the distance at which the patient is sitting from chart and the denominator is the from chart and the denominator is the distance at which person (with normal distance at which person (with normal vision) should be able to read the last line vision) should be able to read the last line that person is able to read.that person is able to read.

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Procedure of testingProcedure of testing

• Patient is seated at the distance of 6 meters Patient is seated at the distance of 6 meters from Snellen’s chart (distance of 6 mts is taken from Snellen’s chart (distance of 6 mts is taken as at this distance it is assumed that the rays are as at this distance it is assumed that the rays are almost parallel and patient exert minimum almost parallel and patient exert minimum accommodation)accommodation)

• The chart should be properly illuminated at The chart should be properly illuminated at minimum of 20 feet candles. Patient made to minimum of 20 feet candles. Patient made to wear trial frame. It is adjusted according to wear trial frame. It is adjusted according to patient inter pupillary distance.patient inter pupillary distance.

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• Ask the patient to read with one eye from the top Ask the patient to read with one eye from the top letter while the contra lateral eye is closed gently letter while the contra lateral eye is closed gently with the patient arm or with occulder in the trial with the patient arm or with occulder in the trial frame. frame.

• Now patient is asked to reads the Snellen’s chart Now patient is asked to reads the Snellen’s chart and depending upon the smallest line which the and depending upon the smallest line which the patient can read from distance of 6mts his vision is patient can read from distance of 6mts his vision is recorded as 6/6, 6/9 ,6/12,6/18, 6/24, 6/36, 6/60.recorded as 6/6, 6/9 ,6/12,6/18, 6/24, 6/36, 6/60.

• But if patient is not able to see the top line from 6mts But if patient is not able to see the top line from 6mts he is asked to come towards Snellen’s charts step he is asked to come towards Snellen’s charts step by step and vision recorded at 5,4, 3, 2, 1 mts and by step and vision recorded at 5,4, 3, 2, 1 mts and noted as 5/60,4/60,3/60,2/60,1/60 respectively noted as 5/60,4/60,3/60,2/60,1/60 respectively

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OccluderOccluder


• If patient is not able to read top line even at the If patient is not able to read top line even at the distance of 1 mts he is asked to count fingers of distance of 1 mts he is asked to count fingers of examiner and his vision is recorded as CF3FT, examiner and his vision is recorded as CF3FT, CF 2FT, CF1FT OR CF close to face . CF 2FT, CF1FT OR CF close to face .

• If patient not able to count examiner finger close If patient not able to count examiner finger close to face then examiner waves or moves his hand to face then examiner waves or moves his hand and asks patient whether he is able to see hand and asks patient whether he is able to see hand movement or not. Visual acuity then recorded as movement or not. Visual acuity then recorded as HM+HM+

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• When patient cannot distinguish hand When patient cannot distinguish hand movements the examiner notes whether the movements the examiner notes whether the patient can perceive light (PL) or not. If he patient can perceive light (PL) or not. If he perceive light it is noted as PL +ve otherwise perceive light it is noted as PL +ve otherwise as PL-ve. Also examiner then throw the light as PL-ve. Also examiner then throw the light from four directions (nasal, superior, from four directions (nasal, superior, temporal, inferior) temporal, inferior)

• and record accordingly. if present patient and record accordingly. if present patient perceive light from all directions it is marked perceive light from all directions it is marked as PR (Projection of rays ) present or else as PR (Projection of rays ) present or else mark as absent or defective. The test is mark as absent or defective. The test is repeated for the other eye in similar fashionrepeated for the other eye in similar fashion

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English chartEnglish chart Landolt ring chart Landolt ring chart

This is the chart containing a series of broken This is the chart containing a series of broken rings, with each gap subtending an angle of 1 rings, with each gap subtending an angle of 1 minute at nodal point at a given distance. minute at nodal point at a given distance.

It is used in illiterate patients.It is used in illiterate patients. E-chart – used in illiterate patients E-chart – used in illiterate patients Simple picture charts for children.Simple picture charts for children.

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Pin hole test Pin hole test Method Method

• After noting vision unaided patient is asked to After noting vision unaided patient is asked to read Snellen’s chart while holding a pin hole read Snellen’s chart while holding a pin hole (hole size is 1mm) exactly in centre of pupil in (hole size is 1mm) exactly in centre of pupil in front of eye. front of eye.

• Now patient’s vision is noted and similar pin hole Now patient’s vision is noted and similar pin hole vision is recorded for other eye also vision is recorded for other eye also

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Pin HolePin Hole

Pin Hole TestPin Hole Test

Interpretation Interpretation • If patient vision is improved with pin hole it If patient vision is improved with pin hole it

means the poor acuity is due to refractive error. means the poor acuity is due to refractive error. • If static acuity means may be due to structural or If static acuity means may be due to structural or

organic cause.organic cause.• If reduced the poor visual acuity may be due to If reduced the poor visual acuity may be due to

corneal opacity or lenticular opacity occupying corneal opacity or lenticular opacity occupying papillary area or macular pathology. papillary area or macular pathology.

Near visionNear vision

Charts for testing near vision are Charts for testing near vision are

1) Snellen near vision chart - 1) Snellen near vision chart -

2) Jaeger chart2) Jaeger chart

3) Roman test type 3) Roman test type

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Method of recording Near visionMethod of recording Near vision

Ask the patient to sit with his back to the light Ask the patient to sit with his back to the light If the patient is using glasses for distance the If the patient is using glasses for distance the

same number will be put on the trial frame. same number will be put on the trial frame. Occlude one eye with an occulder Occlude one eye with an occulder

Ask the patient to hold the near vision by his Ask the patient to hold the near vision by his right hand at a distance of 25 to 33 cms.right hand at a distance of 25 to 33 cms.

Note the near vision as per the letter read Note the near vision as per the letter read Repeat the test for the other eye. Repeat the test for the other eye.

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Examination of head postureExamination of head posture

• Position of head, face and chin should be noted.Position of head, face and chin should be noted.• Note for elevation/depression of chin Note for elevation/depression of chin • Note for any elevation or depression of headNote for any elevation or depression of head• Face turn to right or left Face turn to right or left • In complete Ptosis (chin is elevated to uncover In complete Ptosis (chin is elevated to uncover

the papillary area in a bid to see clearly)the papillary area in a bid to see clearly)• In paralytic squint (head is turned in direction of In paralytic squint (head is turned in direction of

action of paralyzed muscle to avoid diplopia).action of paralyzed muscle to avoid diplopia).

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Blepharophimosis Syndromen note chin elevationBlepharophimosis Syndromen note chin elevation

Examination of foreheadExamination of forehead

• Look for Look for increased wrinklingincreased wrinkling (due to over (due to over action of frontalis muscle) in patient with action of frontalis muscle) in patient with Ptosis.Ptosis.

• Complete loss of wrinklingComplete loss of wrinkling in one half of in one half of the forehead is observed in patient with the forehead is observed in patient with lower motor neuron type of facial palsy lower motor neuron type of facial palsy (seventh nerve palsy).(seventh nerve palsy).

• Facial asymmetryFacial asymmetry may be noted in may be noted in patient with bell’s palsy, musculo-facial patient with bell’s palsy, musculo-facial anomalies and facial hemiatrophy.anomalies and facial hemiatrophy.

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Examination of eye browsExamination of eye brows

Level of the two eyebrowsLevel of the two eyebrows may be may be changed in a patient with Ptosis (due to changed in a patient with Ptosis (due to over action of frontalis)over action of frontalis)

MadarosisMadarosis -Cilia of lateral one third of -Cilia of lateral one third of eyebrows may be absent in patient with eyebrows may be absent in patient with leprosy and Myxoedema.leprosy and Myxoedema.

Scarring in and area around eyebrow Scarring in and area around eyebrow should be notedshould be noted

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Examination of the eyeballExamination of the eyeball

Observe the following points Observe the following points

• PositionPosition – normally the two eyeball are – normally the two eyeball are symmetrically placed in the orbit in such a way symmetrically placed in the orbit in such a way that a line joining the center point of superior that a line joining the center point of superior and inferior orbital margins just touches the and inferior orbital margins just touches the cornea cornea

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a) a) Abnormality of the position eyeballAbnormality of the position eyeball can be – can be – Proptosis /exophthalmos – buldge of the Proptosis /exophthalmos – buldge of the

eyeballs –note eyeballs –note whether proptosis is –axial or eccentricwhether proptosis is –axial or eccentric Reducible or non reducible Reducible or non reducible Pulsatile or non pulsatile Pulsatile or non pulsatile Enophthalmos – (sunken eyeball) Enophthalmos – (sunken eyeball)

Absence of eye ball (clinical) is called Absence of eye ball (clinical) is called Anophthalmos.Anophthalmos.

ProptosisProptosis

Shrunken (small) eye Shrunken (small) eye ballball

Sunken Eye Ball Sunken Eye Ball


b) Visual axis of eyeball b) Visual axis of eyeball Normally the visual axis of the eyeball is Normally the visual axis of the eyeball is

simultaneously directed at same object simultaneously directed at same object which is maintained in all the directions of which is maintained in all the directions of gaze. gaze.

Deviation is the visual axis of one eye is Deviation is the visual axis of one eye is called squint.called squint.

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c) Size of eyeball c) Size of eyeball Measurement of eye is made by Measurement of eye is made by

ultrasonography (A-scan)ultrasonography (A-scan) Size of eyeball is increased in conditions like Size of eyeball is increased in conditions like

buphthalmos and unilateral high myopia.buphthalmos and unilateral high myopia. Size of small sizes eyeball are-congenital Size of small sizes eyeball are-congenital

Microphthalmos, phthisis bulbi and atrophic Microphthalmos, phthisis bulbi and atrophic bulbi bulbi

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d) Movement of eye ball d) Movement of eye ball The movement are tested uniocular The movement are tested uniocular

(duction)as well as binocularly (versions) (duction)as well as binocularly (versions) in all the six cardinal directions of gaze.in all the six cardinal directions of gaze.

Uniocular – Adduction, abduction, Uniocular – Adduction, abduction, depression, elevation, depression and depression, elevation, depression and elevation in adduction and abduction elevation in adduction and abduction

Binocular Binocular

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Binocular Ocular Movements Binocular Ocular Movements 33 3 3

4 5 4 54 5 4 5 1 1 2 1 2 1 2 2 6 7 8 6 7 8 6 7 8 6 7 8

Right sideRight side Left side Left side

1 = Dextroversion; 2 = Levoversion; 3 = Elevation; 1 = Dextroversion; 2 = Levoversion; 3 = Elevation;

4 = Dextroelevation ; 5= Levoelevation; 6= Dextrodepression; 4 = Dextroelevation ; 5= Levoelevation; 6= Dextrodepression; 7= Depression; 8 = Levodepression 7= Depression; 8 = Levodepression

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Documents

Examination of Eye 1. Examination of Anterior Segment Examination of Posterior Segment 2