SUBJECTIVE VISUAL EXAMINATION Eye Examination:

Ask the subject always watch the keratoskope placido during examination, and the examiner watch the cornea of the subject through the hole at the center of keratoskope palcido. The image of the keratoskope placido can be watch at front surface of the cornea in form of black circle. If the image form is full and concentric circle, it mean the surface of cornea is normal If the image form is crooked on one side and difference to the other side, it mean the front surface of the cornea is abnormal. Learning task: what is call astigmatism? what is to correct it? STUDY GUIDE BASIC CLINICAL SKILL OPHTHALMOLOGY CONTENTS: 1. Subjective visual examination 2. External inspection:  Eyelid  Conjunctiva  Sclera  Lachrymal apparatus  Pupil  Light reflex and convergence  Cornea  Camera Oculi Anterior  Iris  Lens 3. Intra Ocular Pressure  Palpation  Tonometry Schiotz 4. Therapeutic Skill  Eyelid eversion  Eye drops installation  Eye ointment installation  Applying eye dressing  Removal conjunctiva foreign body  Removal corneal foreign body with cotton bud

I. SUBJECTIVE VISUAL EXAMINATION Eye Examination:

• Visual Acuity • Visual field examination with confrontation test, perimetry kinetic and static • Dark adaptation – measurement of least luminance required to produce a visual sensation • Contrast sensitivity – is measurement of the smallest distinguishable contrast, it is assessment of quality of vision • Colour vision –with lantern test Edridge green lantern and Isochromatic charts Udayana University Faculty of Medicine, MEU 51 Subjective examination of the function of eye Definition- It is defined as the measurement of the smallest retinal image which can be appreciated with reference to its shape and size. it is actually measure of form sense. • Central or direct vision • Distance vision with Snellen test type • Near vision with Snellen test type or Jaeger’s test type • The principal of assessment is measurement of spatial resolution of the eye i.e. an estimation of ability of eye to discriminate between two points. DISTANCE VISION Two distant points can be visible as separate only when they subtend an angle of 1 minute at the nodal point of eye. Principle • Each individual letter subtends an angle of 5 minutes and each component of letter subtends an angle of 1 minute at the nodal point of eye from the distance in meters written as numerical. • Snellen chart is having different number of letters in different rows and the letter at top line should be read clearly at distance of 60 m. similarly the letters at subsequent lines as are read at 36, 24,18,12,9,6,5mts respectively • Numerical convention is used for recording visual acuity. In fraction, the numerator is the distance at which the patient is sitting from chart and the denominator is the distance at which person with normal vision should be able to read the last line that person is able to read. Udayana University Faculty of Medicine, MEU 52 Procedure of testing • Patient is seated at the distance of 6 meters from Snellen’s chart distance of 6 mts is taken as at this distance it is assumed that the rays are almost parallel and patient exert minimum accommodation • The chart should be properly illuminated at minimum of 20 feet candles. Patient is asked to wear trial frame. It is adjusted according to patient inter pupillary distance. • Ask the patient to read with one eye from the top letter while the contra lateral eye is closed gently with the patient palm or with occulder in the trial frame. • Now patient is asked to reads the Snellen’s chart from top letter to smaller letter, and depending upon the smallest line that the patient can read from distance of 6mt. His vision is recorded as 66, 69, 612,618, 624, 636, 660. • But if patient is not able to see the top line from 6mts he is asked to count the examiner finger at 5,4, 3, 2, 1 mts or reverse, from 1 to 5 mts and noted as 560,460,360,260,160 respectively or CF=counting finger 1m, CF 2m, CF 3m,CF 4m, CF 5m • If patient not able to count examiner finger close to face then examiner waves or moves his hand in about 25 cm from the patient eye and asks patient whether he is able to see hand movement or not. Visual acuity then recorded as HM+ or 1300 • When patient cannot distinguish hand movements, the examiner use penlight in front of the patient eye ± 20 – 25cm and notes whether the patient can perceive light or not. If he perceive light it is noted as LP light perception +ve otherwise as LP-ve. The examiner then reflect the penlight from four directions nasal, superior, temporal, inferior and asked the patient to mention the direction of the light. • Record accordingly if present patient perceive light from all directions it is marked as PR Projection of rays present or else mark as absent or defective. The test is repeated for the other eye in similar fashion Pin hole test Method Udayana University Faculty of Medicine, MEU 53 • Place the pin hole occluder in front of the eye with reduced vision • Ask the patient to move their eye and head until some letters can be read on the letter chart • Ask the patient to read the lowest line of letters he can see looking through the pinhol Interpretation • If patient vision is improved with pin hole it means the poor acuity is due to refractive errors. eg. 612 PH 66 means visual acuity 612 can be improved with pinhole until 66 • If static acuity means may be due to structural or organic cause.eg.612 NI PH = non improved PH means the visual acuity still 612 with non improvement with pin hole • If reduced the poor visual acuity may be due to corneal opacity or lenticular opacity occupying papillary area or macular pathology. Charts for testing near vision are : 1 Snellen near vision chart 2 Jaeger chart 3 Roman test type Method of recording near vision • Ask the patient to sit with his back to the light • If the patient is using glasses for distance the same number will be put on the trial frame. Occlude one eye with an occulder • Ask the patient to hold the near vision by his right hand at a distance of 25 to 33 cms. • Note the near vision as per the letter read • Repeat the test for the other eye. II. EXTERNAL INSPECTION 1. Eyelids Eyelids conditions  Diffuse swollen or edema, usually found in nephritic syndrome, heart disease, anemia, dacryoadenitis and hyperthyroid..  Eyelid swollen with sharp edge in chalazion, tumor.  Blepharospasm, happened on corneal erosin, anterior uveitis, acute glaucoma. Essential Blepharospasm did not result from organic disorders and usually happened billateraly. Blepharospasm could also be found at psychiatric patient with hysteria. Udayana University Faculty of Medicine, MEU 54  Echymosis, the color of the eyelid changes as a result of blood extravatation after trauma.  Ectropion, is turning outward of the eyelids, could be found in elderly, paralise of the muscles, cikatriks and other.  Entropion, turning inward of the eyelids.In Trachomas patient the entropion usually happen in upper eyelids. Entropion could also happen due to parese of the muscles, cikatriks and senile condition.  Lagoftalmos: inabillity to close the eyelids completely.  Redness, inflamation, squama, tumour Merah, radang, keropeng skuama, tumor.  Pseudoptosis, difficulties to open the eyelids as if it is drooping. Happen on enophthalmos, phtisis bulbi, chalazion or the other eyelids tumour, eyelids edema and blepharochalazis.  Ptosis, drooping eyelids. Usually happen in elderly with history of intraocular surgery, Myasthenia gravis, Horner Syndrome, N III palsy, botulinum toxin injection  Cikatriks, scar on the eyelids  Trikiasis, silia atau bulu mata tumbuh salah arah sehingga dapat merusak kornea. Trikiasis dapat disebabkan blefaritis dan entropion.  Xantelasma, penimbunan deposit berwarna kekuning-kuningan pada kelopak, terutama nasal atas dan bawah. Xantelasma biasanya dihubungkan dengan hiperlipidemia dan dapat tanpa hiperlipidemia seperti pada histiosis dan retikulohistositoma. Abnormality of lower eyelids:  Similar with upper eyelids  Swollen of lacrimal sac, redness and sometimes pus came out when it be pushed.  Madarosis. Inerpalpebral Fissure  Normal  Narrow or small, if there is eyelids edema, blepharitis, ptosis, pseudoptosis, blepharophymosis  Wide or bigger, happened in hyperthyroid or intraocular tumour. Eyelids margin  Complete cilia  Trichiasis  Meibomian gland punctum secretion  Redness, pain and ulceration 2. Conjunctiva Upper Tarsal Conjunctiva Can be checked by eversion the upper eyelids using finger or cotton tip applicator. Abnormality of the conjunctiva:  Cobble stone follicles, deposite of macrophages and lymphoid cells under the conjunctiva. Dome shaped appearance, about 1 mm. Most follicles can be seen in forniks area because in this area consist of a lot of lymphoid tissues. Udayana University Faculty of Medicine, MEU 55  Membrane, inflammatory cells beyond the conjunctiva that will be bleed iwhen excised. This membrane usually appears like mass surrounding tarsal or bulbar conjunctiva. It is consists of necrotic tissues, penetrated to the deeper layer and greyish, usually can be found in patient with bacteria conjunctivitis or rarely happened on viral conjunctivitis.  Pseudomembrane, membranes that not get bleed if excised. Happened in ocular pemphygoid and Steven Johnson Syndrome.  Papillae, tiny dome shaped nodule that consist of hyperemic central core blood vessels of the conjunctiva that protrude up and perpendicular to the tarsal plate surrounded by edema and inflammatory cells  Giant Papillae, polygonal shaped, flat and coukd be found in vernal conjunctivitis, superior limbic keratitis, and iatrogenic conjunctivitis.  Cicatriks, in trachoma usually the direction of the cicatriks is parallel with eyelids margin.  Simblepharon, stickyness of tarsal and bulbar conjunctiva and kornea. Can be found in chemical trauma or Steven Johnson Syndromes  Hordeolum or Stye  Chalazion. Inferior tarsal conjunctiva Konjungtiva tarsal inferior The abnormalities could be:  Cobble stone follicles.  Papil.  cicatriks  Hordeolum or Stye.  Chalazion. Bulbar conjunctiva The abnormalities could be:  Discharge  Conjunctival Injection, vasodilatation of superior conjunctival arteries  Cilliary Injection, vasodilatation of pericorneal arteries or anterior cilliaris arteries.  Episcleral injection, vasodilatation of episcleral vessels  Subconjunctival bleeding.  Flickten, inflammatory surrounded with neovascularization on conjunctiva  Simblepharon.  Degeneration plaque  Pinguecula, conjunctival degeneration plaque in palpebral fissure area, triangular shape in nasal and temporal cornea  Pterygium, proliferation of fibrous tissues process with neovascularization on conjunctiva, triangular shape with the apeks toward the cornea  Pseudopterygium.  Flickten, inflammatory cells and neovascularization on the cornea. 3. Sclera Abnormalities that coulb be found in sclera:  Local or diffuse episcleral injection.  Nodulle. Udayana University Faculty of Medicine, MEU 56 4. Lacrimal Apparatus The abnormalities includes:  Epifora.  Stenosis or obstruction of lacrimal punctum  Lacrmal sac inflammation Peradangan di sakus lakrimal.  Yellowish discharge or pus in lacrimal punctum 5. Pupil Pupil abnormalities:  Isokoria, similarities of shape and size of pupil in both eyes  Anisokoria, the size of both pupil is different, found in monocular granuloma uveitis and Afferent pupillary defect  Midriasis, happened as a results of parasympatolitik drugs atropine, skopolamine atau sympatomimetik adrenaline and cocaine.  Miosis, happened in miotic spastics meningitis, ensephalitis dan ventrikel haemorraghe, morfine and antikolinesterase intoxication. In miotic paralitic or simpatic parese as Horner syndrome, miosis, ptosis dan anhidrosis were the Trias.  Hippus, also known as pupillary athetosis, is spasmodic, rhythmic, but irregular dilating and contracting pupillary movements between the sphincter and dilator muscles  Pupil occlusion, pupil covered by inflammatory tissues in front of the lens  Seklusi pupil, the whole pupil is attached to anterior lens  Leukokoria, white pupil or whitish reflex of the pupil. Can be found in cataract, retrolental fibroplasia, endophthalmitis, vitreous hyperplasia, high myopia, retinal detachment andretinal tumour as retinoblastoma  No pupil reaction, can be found in intoxication of mydriatics and miotic drug, sphincter pupil rupture, posterior sinekia, blind Light reflex and convergence  Positive light reflex, miotic effect when pupil get exposed to the light  Negative light reflex, happened on sphincter pupillae rupture, no Light perception patient, parasympatic abnormalities, drug induced angd posterior synekia  Convergence reflex consist of accommodation, miosis and convergence if there is a changes focus from far point to near point. Kornea Abnormalities of the cornea:  Normal corneal diameter is 12 mm  Macrocornea: diameter of the corena is larger than normal  Microcornea: diameter of the cornea is smaller than normal  Arkus senilis, whitish or grey ring in outer segement of cornea  Corneal edema, the cornea is unclear and thickened, happened in congenital glaucoma as well as acute glaucoma, after intra ocular surgeries, endothelial decompensation, trauma and corneal infection Udayana University Faculty of Medicine, MEU 57  Erosion, corneal epithelial detachment, give rise to positive fluourescein test  Infiltrat, deposit of inflammatory cells on the cornea that makes cornea unclear and positive placido test  Pannus, inflammatory cells with neovascularization, usually at the superior limbal area of the cornea, happened in trachoma, contact lens warpage, flicten, superior limbic keratoconjunctivitis and corneal burn  Corneal Ulcer, loss half of corneal layer due to necrosis in infection or allergic condition  Corneal Xerosis, the dryness of the corneal surface and unclear cornea.  Keratomalasia, softened and protruded cornea  Cicatriks, scar on the cornea, consist of nebula, macula and lecoma  Leukoma adheren, cornea is attached to the iris  Corneal Staphyloma, protrusion of the cornea due to corneal ulcer or cornea become thin with exposed uvea in the back of the cornea  Keratik presipitat, inflammatory cell in the corneal endothel 6. Anterior Chamber Abnormalities:  Shallow anterior chamber in lens dislocation, iris tumour, anterior synekia, iris bombe due to pupillary block and acute glaucoma  Deep anterior chamber, in aphakia, myopia, congenital glaucoma and angle resession  Flare, deposit of inflammatory cells and fibrin in anterior chamber  Hipopion, the deposit of inflammatory cells in lower part of anterior chamber. 7. Iris Abnormalities:  Coloboma  Aniridia  Iris atrophy  Rubeosis iridis, neovascularization in the iris  Anterior Synekia, attachment of the iris with cornea  Posterior Synekia, attachment of the iris to the lens 8. Lens Abnormalities:  Cataract, clouding of the lens  Lens dislocation, changes in lens position from its normal position, can be subluxated or luxated to anterior or posterior II. TONOMETRI 1.PALPATION TONOMETRI Basic: intra ocular pressure measurement by examiner finger Instrument: examiner finger tekanan bola mata dengan jari pemeriksa. Technique Udayana University Faculty of Medicine, MEU 58  The patient close his eyes Penderita memejamkan mata with down gaze  One of the pointing finger pushed the eyeball while the other finger constantly hold the eyeball, and the other finger hold the forehead and patient chin. Interpretation  The eyeball soft enough when it is pushed by finger N = normal palpation  N+1, N+2, N+3 atau N-1, N-2, N-3 is the notation that show the higher or lower intraocular pressure  If the intraocular pressure is higher than normal the glaucoma is suspicious Notes This methods can be used if tonometry is not available or the tonometry could not be used in some eye condition such as cicatriks on the cornea, irregular cornea and corneal infection. This methods need more practical skill because of subjective interpretation. Beware of oculo cardiac reflex if the eyeball being pushed innapropiatelly.

2. SCHIOTZ TONOMETRI