Anatomy, Physiology, & Examination of the Eye

Hariyah M. Mahdi, MD.Ophth. Department of Ophthalmology Medical Faculty Brawijaya Univ. / dr.Saiful Anwar Hospital

Embryology; Anatomy & Physiology of the Eye

EMBRIOLOGY Developmental Phase: Optic Vesicle phase Optic Cup phase Origin : Ectoderm and Mesoderm. Optimal Growth & development: at 7 8 y.o.

ANATOMY of the EYE

Orbita

Eye

Ball: - The wall & content of the eye Extraocular muscle Adnexa Lacrimal apparatus Optic nerve / N.II
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ORBITA

Retina Sclera Choroid

Vitreous Humor

Fovea
Lens

Lens Muscle Ligaments Iris

Pupil Cornea

The Human Eye

Optic Nerve Blind Spot eyelid

Aqueous Humor
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Extraocular Muscle

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ADNEXA

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The Optic Nerve (N. II)

Part of anterior visual pathway (optic nerve, optic chiasm, optic tract) Light retina optic nerve brain

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Lacrimal system

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Physiology of the Eye

Visual

function Refractive media Optic nerve Optic chiasm Visual tract Occipital lobe

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Visual pathway

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Ocular Examination

Routine Examination General Information

Every examination should start with acquiring IDENTITY This include: Name : Age : Address: Occupation: This step is important to build COMMUNICATION with the patient and also gives clue to disease possibilities. Besides obtaining patient identification, we must also introduce our self and obtain permission for examining the patient.
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Continued
Symptoms & Signs: 5 Categories
1. 2. 3. 4. 5. Subnormal Visual acuity Pain or discomfort Change of appearance of lids, orbit, or eye Diplopia or dizziness Discharge or increased conjunctival secretion

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ANAMNESA

Very Important (assist up to 70% of diagnosis) includes:

General ANAMNESIS: - Chief complaint - Previous ilness

- Family history

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Specific Ophthalmological anamnesis

Symptoms must be very specific on:

- ONSET (acute/abrupt, gradual, or unnoted)

- DURATION (intermittent or continuous)

- LOCATION (focal/diffuse; unilateral or bilateral)

- SEVERITY (mild, moderate, or severe)

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Specific Ophthalmological anamnesis

A. Disturbance of visual function B. Disturbance of eye appearance C. Sensation of PAIN and photophobia D. Alteration of eye color E. Secrete on the eye

F. Used medication
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Basic Examination
Visual

Acuity: central and periphery Central Visual Acuity: natural and with correction With Snellen chart, E chart, Landorp ring Finger counting Hand movement Light Perception
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Peripheral vision
The

function of peripheral retina with:

Examination

- Confrontation test. - Tangenscreen. - Perimetry.

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Examination of the external part of the eye

Must be Systematical (Starting with inspection) From outside to inside (anterior to posterior) External part of the eye is inspected with aid of flashlight up to the lens

If necessary, can be assisted by palpation ; and other device such as loupe ; slit lamp;

color dye, etc.

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Examination of internal part of the eye

Need

specific equipment./ Biomicroscope Ophthalmoscope direct and indirect. The part that must be evaluated.: -. Refractive media. -. Blood vessel of the retina ; optic disk and macula.

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SPECIFIC EXAMINATION.

TONOMETRI. To measure Intra Ocular Pressure PLACIDO DISC PERIMETRY.

COLOR VISION TESTBOOK.

GONIOSCOPY. FUNDAL FLUORESCEIN ANGIOGRAPHY etc.

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Drugs used for helping Examination and Diagnostic

Topical

anesthesia. Mydriaticum. Fluorescein ; Mercurochroom; Rose Bengal.

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EXAMINATION OF INFERIOR CONJUNCTIVA AND FORNIX 1. Patient looks down, press skin on inferior palpebra with forefinger downward towards maxilla. (fig 1A) 2. Ask patient to look up, which will expose most of the inferior conjunctiva (fig 1B) 3. Observe: -. Color of conjunctiva (paleness) -. Blood vessel dilatation / hyperemia -. Papillary / follicular hypertropia -. Presence of membrane or pseudomembrane -. Presence of hordeolum interna ; chalasion and other abnormality

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EXAMINATION OF SUPERIOR CONJUNCTIVA Two hands method With fore and pointing finger grasp the eyelash and pull eyelid away from eye (fig 2A ). Place an applicator horizontally over eyelid base along the tarsus, hold the applicator on the temporal side of the eye (fig 2B).

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3. Pull the edge of eyelid outward and superiorly and flip the eyelid over the applicator (fig 2C). Remove the applicator and examine the superior tarsal conjunctiva (fig 2D).

Figure 2C

Figure 2D

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One hand method 1. While patient looking up, put hand on the temporal side of the examined eye, use forefinger to hold the inferior eyelid (fig 3A). 2. Place the pointing finger over superior eyelid and ask patient to look down, and not to the sides (fig 3B).

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3. 4.

Close the eyelids together placing the superior palpenra over the inferior one. (fig 3C) Place the edge of pointing finger over the superior tarsus and press it downward (fig 3D).

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With rotation of finger and wrist, fold the superior eyelid to expose the superior palpebral conjunctiva. The forefinger holds the eyelid towards the superior orbita (fig 3E).

Observe for abnormalities as above

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EXAMINATION OF INTRAOCULAR PRESSURE. DIGITAL METHOD Basic: Examination by fingers, this is the easiest way, but not very accurate and cannot be used for routine examination of a glaucoma patient. This method is used only when no tonometer is available or cannot be used, such as in corneal infection or corneal irregularities cases. Techniques : 1. Inform the patient about the procedure. 2. Patient sits comfortably and looks down, but not closing the eye (this can cause raise of pressure by tarsal muscles). 3. Use fingers from two hands, the fingers rest on patients cheek and forehead.

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4. Both fingers press the eyeball behind the cornea through eyelid one at a time. 5. One finger is pressing while the other feels the counterpressure oof the sclera. 6. Pressure on the eye is measured as N+1, N+2, N+3 and if softer with N-1. N = Normal ; N+ increased pressure; N- decreased pressure

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TONOMETRI WITH SCHIOTZ TONOMETER. Buku Ilmu Penyakit mata PERDAMI. ; Pemeriksaan mata Dr Sidharta Ilyas. ( HAL 141 142. ) Basic. Schiotz Tonometer is an indentation device that presses the cornea with a movable load on its axis. PURPOSE To measure the intraocular pressure Tools Topical eye anesthetic Schiotz tonometer. Technique 1. Inform the patient about the procedure 2. The patient rest on a bed without pillow. 3. Apply topical anesthetic (tetracain) 4. Open the lids with fingers and avoid pressing the eyeball.
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5. 6. 7. 8.

Ask patient to look at ceiling or his own finger placed in front of the eye. Place the base of tonometer on the central cornea. After acquiring a stable reading on the scale, record the reading (between 0-15). When the reading is 3 or smaller, add the load and redo the measurement

Value The pressure value is determined by a given scale (in mmHg) Pressure over 20 mmHg is suspected of glaucoma Pressure over 25 mmHg is suggestive of glaucoma

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Note The Schiotz tonometer should be sterilized each time of use at least with alcohol to prevent infection transmission. Schiotz tonometer is not accurate compared to applanation on several condition such as high myopia and thyroid disease because of influence of scleral rigidity.

- Tonometer Schiotz - Tonometer Schiotz and the loads of 5.5; 7.5 & 10.0 grams.

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 The value reading sometimes are not accurate because of scleral rigidity factor. In this condition, the results should be compared through the Friedenwald table. The result can then be converted to obtain the value in mmHg.
Tonometer is a device to measure the intraocular pressure. It can detect if a person has an increased or decreased intraocular pressure.

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CORNEAL SENSITIVITY TEST

Description / Indication Corneal sensation diminish in several disease such as herpes keratitis, trachoma, corneal degeneration, vernal conjunctivitis, corneal scar, and glaucoma. Other conditions also decrease sensation including contact lens wear, 3-5 months after eye surgery, central nervous system disease, (brain tumor). Herpes simplex keratitis can diminish corneal sensitivity even after the acute phase is over. Topical anesthetic must not be used if this test is needed. Other procedures that affect the cornea, conjungttiva and eyelid should be postponed until after this test.
Instruments Sterile Cotton Applicator

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Technique 1. Inform the patient about the test. Ensure that the test will not cause pain. Ask the patient to tell when he feel the cotton touching the eye. 2. Make a cotton wisp on the applicator. Observe the cornea and ascertain that there is no defect or irritation that can interfere with the examination result. 3. Ask patient to sit and look upward. Move the cotton wisp toward central cornea and touch it without being seen by patient. Carefully rub the cornea until the patient notify the feel of the cotton or it is bent. Test the other eye and ask patient to compare the level of sensation between the two eyes. The test can be repeated after at least 30 seconds.

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5.

This test can be repeated several times after some rest. Ask the patient about the sensation without touching the cotton to cornea to make sure the patient is telling the truth. After the test, evaluate the cornea with fluorescein to see if there is any defect caused by the test. Explain to the patient that his eye may feel foreign body sensation for a few hours.

Interpretation Corneal sensation can be graded, the lowest is when there is no response at all. Patient can also compare between two eyes providing the other eye is healthy.

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Blindness

Definition: Visual Acuity 3/60 or 20/200 or less in the better eye with best correction Or Widest diameter of visual field subtending an angle to 20 degrees Alternative functional definition: Loss of vision sufficient to prevent an individual from supporting himself in occupation
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Incidence of blindness throughout the world: Pakistan: 1% of population India & China: 0.5% Indonesia: 1.5 %
Areas of the eye afflicted by major blindingdisease: Anterior segment diseases: Trachoma Xerophthalmia Onchocerciasis Leprosy Cataract Herpes simplex keratitis
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 Posterior

segment disease Glaucoma Retinal degeneration Retinal Detachment

The greater detail are discussed in: Glaucoma Cataract Retinal Detachment Diabetic Retinopathy
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 Prevention

of blindness Rehabilitation of the Blind - Low vision aid clinics - Braille - Mobility training - Guide dogs - Electronic devices

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