Anterior Chamber Iris Lens SCHIOTZ TONOMETRI

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  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

Udayana University Faculty of Medicine, DME 54 The Schiotz tonometer was once the most widely used tonometer. It is used much less often in today’s office setting, but still serves as an accurate, inexpensive, portable, autoclavable instrument for use in the operating room or in nonophthalmologic or nonoptometric settings. The instrument is a simple mechanical device that employs a weight to press a freely moving plunger against the cornea, indenting it. The amount of indentation produced by this weight is read from a scale with a needle indicator moved by the plunger. The plunger must move freely within the cylinder of the tonometer, so the instrument must be kept scrupulously clean. Any debris or oils from the hands can accumulate in the cylinder and affect the movement of the plunger. The Schiotz tonometer. Courtesy of Sklar Instruments Cleaning the Tonometer The entire instrument must be carefully cleaned between each patient to avoid the possible spread of infection. The instrument is made entirely of metal, so it can withstand steam sterilization and noncorrosive chemical disinfection. However, it is more common to clean the tonometer with isopropyl alcohol. Calibrating the Schiotz A metal test block is provided with every instrument. It is in the corner of the storage box and should be wiped clean before use. The calibration is checked by resting the tonometer perpendicularly on the test block. The needle should indicate zero on the left end of the scale. If it does not, a small screw at the base of the needle can be loosened to rezero the needle. The needle itself should be perfectly straight because bending it will give a false reading. Udayana University Faculty of Medicine, DME 55 The instrument is placed on the test block to test calibration. Photo by Mark Arrigoni. Reprinted from Herrin MP. Ophthalmic Examination and Basic Skills. Thorofare, NJ: SLACK Incorporated; 1990. Performing Schiotz Tonometry The patient must be reclining so that the eyes are looking straight up at the ceiling. A drop of anesthetic is instilled in each eye. The patient is instructed to relax and keep both eyes open and positioned straight ahead; a target placed on the ceiling is helpful. The tonometer should already have been cleaned and tested. A right-handed assistant should hold the tonometer in the right hand using the 2 curved arms attached to the side of the cylinder. The scale mount rotates easily and should be turned so that the scale is facing the assistant. The left hand is used to gently hold the lids of the patient’s right eye apart, anchoring them against the orbital rim so that no pressure is applied to the globe. An alternative hand position is to hold the upper lid with the left hand and the lower Lids with the small finger of the right hand. In either case, the hand holding the tonometer can rest on the patient’s cheek or forehead for stability. The tonometer is gently lowered onto the eye so that the footplate rests on the central cornea and the instrument is perpendicular. The cylinder is then lowered slightly, so that the tonometer is resting on the eye and the assistant is providing only lateral support. The cylinder should neither lift up nor press down on the footplate at this point. Looking straight at the scale, the needle position is noted. If the scale is not directly facing the assistant, an erroneous reading will be made. The tonometer is quickly lifted straight up off. Because the plunger indents the cornea, any movement of the tonometer while it is on the eye may cause an abrasion. The scale readings do not indicate IOP in mm Hg but must be converted according to a table provided with the instrument. The scale readings are inversely proportional to the IOP; lower numbers indicate higher pressures. The standard weight on the plunger is 5.5 gm, and 2 additional weights 2.0 and 4.5 gm may be added to this for a total of 7.5 and 10.0 gm, respectively. If the scale reading is less than 3 ie, the IOP is more than 25, the next weight is added, and the measurement is taken again. If the 7.5 weight still gives a reading of less than 3, then the third weight is added, and the measurement is retaken. Along with the IOP, the assistant should also document the weight used. Udayana University Faculty of Medicine, DME 56 Manual technique for Schiotz tonometry. Courtesy of Sklar Instruments.

IV. THERAPEUTIC SKILL 1. EYELID EVERSION

2. EYE DROP INSTILATION 3. EYE OINTMENT INSTILLATION 4. APPLY EYE DRESSING 5. REMOVAL CONJUNCTIVAL FOREIGN BODY

6. REMOVAL CORNEAL FOREIGN BODY WITH COTTON BUD

1. EYELID EVERSION INFERIOR CONJUNCTIVA AND FORNIKS EXAMINATION