1.
eyelid and anterior segment examination
A slit lamp is an instrument consisting of a high-intensity light source
that can be focused to shine a thin sheet of light into the eye. It is
used in conjunction with a biomicroscope. The lamp facilitates an
examination of the anterior segment and posterior segment of the
human eye, which includes the eyelid, sclera, conjunctiva, iris, natural
crystalline lens, and cornea.
2.visual acuity examination.
A Snellen chart is an eye chart that can be used to measure visual
acuity.
The normal Snellen chart is printed with eleven lines of block letters.
The first line consists of one very large letter, which may be one of
several letters, for example E, H, or N. Subsequent rows have
increasing numbers of letters that decrease in size. A person taking
the test covers one eye from 6 metres or 20 feet away, and reads
aloud the letters of each row, beginning at the top
Snellen fraction D/d
Visual acuity = Distance at which test is made / distance at which the
smallest optotype identified subtends an angle of five arcminutes
3.visual field examination.
Methods of assessing visual fields
(Donders)(confrontation tests)
The examiner will ask the patient to cover one eye and stare at the
examiner. Ideally, when the patient covers their right eye, the
examiner covers their left eye, and vice versa. The examiner will then
move his hand out of the patient's visual field and then bring it back
in. Commonly the examiner will use a slowly wagging finger or a hat
pin for this. The patient signals the examiner when his hand comes
back into view. This is frequently done by an examiner as a simple
and preliminary test
perimetry
Perimetry or campimetry is one way to systematically test the visual
field.[1][failed verification] It is the systematic measurement of
differential light sensitivity in the visual field by the detection of the
presence of test targets on a defined background. Perimetry more
carefully maps and quantifies the visual field, especially at the
extreme periphery of the visual field. The name comes from the
method of testing the perimeter of the visual field.
Types of perimetry:
-ferster perimeter
-the perimeter of light projection
-spheroperimeter
-humphrey perimeter
4.chrmoatic vision examination
• Color vision tests:
– nomination
– matching and classification
– confusion or discrimination
– equalization
Pseudoisochromatic tables:
The test includes several pseudoisochromatic plates, each composed
of a pattern of differently shaded dots. Within each pattern, a
number is present.
To a color-deficient person, all the dots in one or more of the plates
will appear similar or the same—“isochromatic.” To a person
without a color deficiency, some of the dots will appear dissimilar
enough from the other dots to form a distinct figure (number) on
each of the plates—“pseudoisochromatic.”
5.examination of binocular vision and eye movements.
-test worth:
Worth Four Light Test simple to undertake.
First you must place the red/green glasses over the patients eyes,
with the red glass traditionally placed over the right eye.
Next you must dim the room lighting. This allows the patient to see
the lights better.
For a distance measurement, you should have the patient set up 6
metres away from the light source.
Then, ask the patient what they see. They should respond with “I see
… number of lights” provided they have understood what you have
asked them. Ask them to describe the lights to you. You must ask
about the colour of the lights. If they see five lights, ask whether the
green dots are higher or lower than the red dots. Ask about the
positioning of the dots, for example are the red dots to the left or the
right of the green dots. Also ask if the dots are flashing on and off or
switching between red and green. And then record the answers.
-socolov test
6.light sensibility examination
Essential function • Rods are more sensitive then cons. For stimulate
the rods are enough some photons • Adaptation: – To light – 1-3 min
– To dark – 40-60 min, dereglation - hesperanopies (hemeralopies)
Goldmann weekers adaptometer
Dark adaptation is most often tested on an instrument such as
the Goldmann-Weekers adaptometer .The patient is first light-
adapted to a bright background light. This light is then extinguished,
and the patient, now in the dark, is presented with a series of dim
light targets approximately 11° below fixation. The intensity of the
test lights is controlled by neutral-density filters, and the threshold at
which the test light is perceived is plotted against time. Under these
conditions, the dark adaptation curve., shows 2 plateaus: the first
represents the cone threshold, which is usually reached in 5–
10 minutes, and the second represents the rod threshold, which is
reached after about 30 minutes. If the clinical interest is limited to
rod sensitivity in the dark, the test can be shortened by eliminating
the first step of adaptation to bright light and recording only an
endpoint rod threshold, which is normally reached within about 10
minutes of dark adaptation.
7.eye refraction examination.
There are 4 common types of refractive errors:
Nearsightedness (myopia) makes far-away objects look blurry
Farsightedness (hyperopia) makes nearby objects look blurry
Astigmatism can make far-away and nearby objects look blurry or
distorted
Presbyopia makes it hard for middle-aged and older adults to see
things up close
DIAGNOSIS of refractive errors
•Subjective methods:
•Trial lenses. The patient look through a variety of lenses until an
appropriate optical correction is determined.
•Objective methods:
•Retinoscope
•automated refractor
8.general rules in prescriptions of glasses for: myopia ,hyperopia,
presbyopia
There are 3 degree of myopia:
•I degree from -0,5 to -3,0D
•II degree -3,25D − -6D
•III degree - 6,25 − ↑
Myopia treatment
•Divergent lenses : minus (-)
•Avoid Overcorrection!!!
There are 3 degree of hypermetropia:
●I degree +0,5 – +3,0D
●II degree +3,25D – +6,0D
●III degree + 6,25 − ↑
Hypermetropia treatment:
•Convergent lenses: plus (+)
presbyobia
Optical treatment:
- glasses (convergent (+ lenses))
- contact lenses
•40 years +1,0D (+0,5)
•50 years +1,0D -+2,0D
•60 years +2,0D -+3,0D
•70 years +3,0D -+4,0D
•This correction is added to the distant optical correction of the
patients.
9.squint examination: Hirschberg method and cover test.
the Hirschberg test, also Hirschberg corneal reflex test, is a screening test that
can be used to assess whether a person has strabismus (ocular misalignment).
cover test
A cover test or cover-uncover test is an objective determination of
the presence and amount of ocular deviation.
The two primary types of cover tests are:
• the alternating cover test
• the unilateral cover test (or the cover-uncover test).
The test involves having the patient (typically a child) focusing on a
near object. A cover is placed over an eye for a short moment then
removed while observing both eyes for movement. The misaligned
eye will deviate inwards or outwards. The process is repeated on both
eyes and then with the child focusing on a distant object.
10.examination of lacrimal system(permeability and function).
Schirmer's test determines whether the eye produces enough tears to
keep it moist.
Tear breakup time (TBUT) is a clinical test used to assess for
evaporative dry eye disease. To measure TBUT, fluorescein is instilled
into the patient's tear film and the patient is asked not to blink while
the tear film is observed under a broad beam of cobalt blue
illumination. The TBUT is recorded as the number of seconds that
elapse between the last blink and the appearance of the first dry spot
in the tear film, as seen in this progression of these slit lamps photos
over time. A TBUT under 10 seconds is considered abnormal. This
patient also has punctate epithelial erosions (PEE) that stain
positively with fluorescein, another sign of ocular surface dryness.
11.examination of pupillary reflex.
The pupillary light reflex (PLR) or photopupillary reflex is a reflex that
controls the diameter of the pupil, in response to the intensity
(luminance) of light that falls on the retinal ganglion cells of the
retina in the back of the eye, thereby assisting in adaptation of vision
to various levels of lightness/darkness. A greater intensity of light
causes the pupil to constrict (miosis/myosis; thereby allowing less
light in), whereas a lower intensity of light causes the pupil to dilate
(mydriasis, expansion; thereby allowing more light in). Thus, the
pupillary light reflex regulates the intensity of light entering the
eye.[1] Light shone into one eye will cause both pupils to constrict.
12.Intraocular pressure(IOP) measurement.
Eye Tonometry
•Instrumental:
–indentation
–aplanation
–electronic
–transpalpebral
–non-contact (air-push)
•Tactil:
–palpatory;
Intraocular pressure is measured with a tonometer as part of a
comprehensive eye examination.
Applanation tonometry
In applanation tonometry the intraocular pressure (IOP) is inferred
from the force required to flatten (applanate) a constant area of the
cornea, for the Imbert-Fick law.[2] The Maklakoff tonometer was an
early example of this method, while the Goldmann tonometer is the
most widely used version in current practice.[3] Because the probe
makes contact with the cornea, a topical anesthetic, such as
proxymetacaine, is introduced on to the surface of the eye in the form
of an eye drop.
Goldmann tonometry
Goldmann tonometry is considered to be the gold standard IOP test
and is the most widely accepted method A special disinfected prism is
mounted on the tonometer head and then placed against the cornea.
The examiner then uses a cobalt blue filter to view two green
semicircles. The force applied to the tonometer head is then adjusted
using a dial connected to a variable tension spring until the inner
edges of the green semicircles in the viewfinder meet. When an area
of 3.06 mm (0.120 in) has been flattened, the opposing forces of
corneal rigidity and the tear film are roughly approximate and cancel
each other out allowing the pressure in the eye to be determined
from the force applied. Like all non-invasive methods, it is inherently
imprecise and may need to be adjusted.
–indentation
13.Ocular chemical burn-(emergency)treatment
Thermal burns- first involves the eyelids; but can be exposed to
combustion and the eyeball;
• Chemical burns
- they are more common and can be caused by various chemical
agents, used in agriculture, industry, construction, alimentation
with acids, which cause the coagulation of the albumin, in result
obtaining a protective "layer", which prevents deeper penetration of
the chemical agent, thereby limiting its harmful action;
– with alkaline, they are considered more dangerous than those
caused by acids, because these chemicals cause the colliquation of
the albumin and penetrate deeper and deeper into the tissue.
Eye burn treatment
the first assistance;
• the specialized treatment:
– medical;
– surgical
First aid in chemical eye burn
the immediately irrigation of the injured eye with
copious quantities (≈ 2 litri) of salin solution
(0,9%) or clean water about 30 – 40 minute;
• removing of the solid particles from the
conjunctival bag (under the upper and lower
eyelids)
medical treatment in eye burn
prophylaxis of infection complication (antibacteriens
topic);
• induction of regeneration, epitelisation, contact lens etc;
• stop of eye inflammatory response (antiinflamatories topic,
systemic, mydriatics);
• regulation of IOP (hypotensives topic, diuretics);
• prevention of eye burns complications (like symblepharon,
corneal opacity etc)
surgical treatment in eye burn
excision of a necrotic tissue;
• anterior chamber paracentesis in the first day for
evacuation of aquos humor with chemical agents (in
special in alkaline burns);
• cover of cornea by amniotic membrane;
• treatment of complications:
– reconstruction of conjunctival bag (symblepharon, scars etc);
– filtering surgery in secondary glaucoma;
– keratoplasty;
– keratoprotesis
14.removing of conjunctival foreign body and corneal foreign body
Conjunctival Trauma:
Edema
• Redness (conjunctivitis)
• Hemorrhages (conjunctival,
subconjunctival)
• Conjunctival foreign body
• Ruptures, wounds
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Conjunctival foreign body: – foreign body sensation – tearing –
blepharospasm – redness – it is removed by cotton (or by irrigation)
– if it is necessary - with the upper eyelid eversion
Superficial eyeball trauma
Corneal erosion
• Corneal foreign body
• Keratitis
• Nonpenetrating injury
(lamelar laceration)
****************************************
Corneal foreign body
they are characteristics predominantly to the people, whose activity
is
related to the processing of metals;
• the appearance of the foreign body sensation is mentioned
clinically; the
presence of a corneal syndrome, usually, not pronounced;
• in the case of a central positioning, visual disturbances may occur;
• the foreign body is viewed biomicroscopically (or by examination
with
lateral illumination)
• to extract it is used a sharp instrument (ex. syringe needle) after
local
anesthesia by instillation of topical anesthetics
– in case of late addressing to the doctor it is usually necessary to
remove the foreign body
with the adjacent modified corneal tissue, which will ensure a
faster healing.
• after removal of the topical foreign body, antibacterials (eye
drops,
ointment) are administered, depending on the case - mydriatics,
contact
lens/monocular punch, drugs for corneal regeneration/rehealing.
15.localization of intraocular foreign body
• Computed Tomography
• komberg – Baltin Radiography
• Ocular ultrasonography
Komberg Baltin method:
on the profile cliché will be present the image of the foreign body
and - in the case of an ideally correct position - only three
landmarks as result of overlapping of the 3 and 9 o'clock points • it
is considered that the right line drawn vertically through the 12 and
6 o'clock landmarks coincides with the plane of the ocular limbus •
based on this cliché, measuring the minimum distance between the
image of the foreign body and this landmark line, the third location
index is appreciated: – depth of placement of the foreign body from
the limbus (mm). Having the three location indices: - the meridian -
the distance from the anatomical axis - the distance from the
limbus one can conclude about the position of the foreign body
(intraocular, extraocular).
16.posterior segment examination(retinoscopy)
Retinoscopy (Ret) is a technique to obtain an objective
measurement of the refractive error of a patient's eyes.The
examiner uses a retinoscope to shine light into the patient's eye and
observes the reflection (reflex) off the patient's retina. While
moving the streak or spot of light across the pupil the examiner
observes the relative movement of the reflex or manually places
lenses over the eye (using a trial frame and trial lenses) to
"neutralize" the reflex.
Static retinoscopy is a type of retinoscopy used in determining a
patient's refractive error. It relies on Foucault knife-edge test, which
states that the examiner should simulate optical infinity to obtain
the correct refractive power. Hence, a power corresponding to the
working distance is subtracted from the gross retinoscopy value to
give the patient's refractive condition, the working distance lens
being one which has a focal length of the examiner's distance from
the patient (e.g. +1.50 dioptre lens for a 67 cm working distance).
Myopes display an "against" reflex, which means that the direction
of movement of light observed from the retina is a different
direction to that in which the light beam is swept. Hyperopes, on
the other hand, display a "with" movement, which means that the
direction of movement of light observed from the retina is the same
as that in which the light beam is swept.
Static retinoscopy is performed when the patient has relaxed
accommodative status. This can be obtained by the patient viewing
a distance target or by the use of cycloplegic drugs (where, for
example, a child's lack of reliable fixation of the target can lead to
fluctuations in accommodation and thus the results obtained).
Dynamic retinoscopy is performed when the patient has active
accommodation from viewing a near target.
Retinoscopy is particularly useful in prescribing corrective lenses for
patients who are unable to undergo a subjective refraction that
requires a judgement and response from the patient (such as
children or those with severe intellectual disabilities or
communication problems). In most tests however, it is used as a
basis for further refinement by subjective refraction. It is also used
to evaluate accommodative ability of the eye and detect latent
hyperopia.
17.general rules in ocular drops instillation and application
ointment
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