BASIC EXAMINATION OF THE EYE

ORI APRISIA PUTRI

I11108023

Eye examination requirement

Adequate light intensity

Available tools and diagnostic drug
Systematic
Know anatomy physiology and pathology
Medical record

The chief complain

: symptoms,
onset, duration,
and cause of the
problem

A
Allergies/Drug
Reactions:
penicillin, contact
dermatitis,
chemical reactants
or food or
environmental
allergies

Past Medical
History: Vascular
disorders
commonly
associated with
ocular
manifestations
such as diabetes
and hypertension

Past ocular
histori : refractive
history, prior eye
infections or
injury, medical
and/or surgical
treatment

Ophthalmic
History

Family Medical
History:
strabismus,
amblyopia,
glaucoma, or
cataracts, and
retinal problems

Medication : Many
systemic
medications may
have an effect on
the eye and on the
patient's visual
acuity and/or
visual field

Common Ocular Symptoms

Abnormalities of vision
Abnormalities of ocular appearance
Abnormalities of ocular sensation pain and
discomfort

1. Abnormalities of vision

a. Visual Loss
Cause by abnormalities Optical and
neurologic visual pathway

refractive (focusing) error

lid ptosis
clouding or interference from the ocular media
(eg, corneal edema, cataract, or hemorrhage in
the vitreous or aqueous space)
malfunction of the retina (macula), optic nerve, or
intracranial visual pathway

b. Visual Aberrations
Glare or haloes uncorrected refractive error, scratches,
pupillary dilation, and hazy ocular media (corneal edema or
cataract)
Visual Distortion irregular pattern of dimness, wavy or jagged
lines, and image magnification or minification (the aura of
migraine, optical distortion from strong corrective lenses, or
lesions involving the macula and optic nerve)
Flashing or flickering retinal traction or migrainous
scintillations (a few second or minutes)
Floating spots may represent normal vitreous strands due to
vitreous "syneresis" or separation
Oscillopsia is a shaking field of vision due to ocular instability
Double vision is monocular or binocular (disappears if one eye is
covered)

2. Abnormalities of appearance

"red eye redness of the lids and

periocular area versus redness of the globe
The latter (subconjunctival hemorrhage or by
vascular congestion of the conjunctiva, sclera,
or episclera external surface inflammation
Changes in appearance of the globe
pterygium, and asymmetry of pupil size,
called "anisocoria
The lids and periocular tissues edema,
redness, focal growths, and lesions, and
abnormal position or contour, such as ptosis

3. Pain & Discomfort

Periocular pain tenderness of the lid, tear sac, sinuses, or

temporal artery
Retrobulbar pain all orbital inflammations, nonspecific
complaints such, as "eyestrain," "pulling," "pressure," "fullness,"
and certain kinds of "headaches," are poorly localized.
Ocular pain Corneal epithelial damage or foreign body
sensation, Corneal epithelial damage typically produces a
superficial sharp pain or foreign body sensation exacerbated by
blinking.
Eye Irritation : Superficial ocular discomfort usually results
from surface abnormalities. Symptoms :

Itching
Dryness
Tearing
secretions

Basic Ophtalmologic examination

The purpose is to evaluate:

Function includes vision and nonvisual
functions, such as eye movements and
alignment
anatomy ocular problems can be subdivided
into three areas: those of the adnexa (lids and
periocular tissue), the globe, and the orbit.

1. Refraction Test

An emmetropic eye is naturally in optimal focus

for distance vision.
An ametropic eye (myopia, hyperopia, or
astigmatism) needs corrective lenses to be in
proper focus for distance.
This optical abnormality is called refractive
error
Refraction is the procedure by which any
refractive error is characterized and quantified
Refraction is often necessary to distinguish
between blurred vision caused by refractive error
or by medical abnormalities of the visual system

2. Testing Central Vision

Snellen chart" is
composed of a series of
progressively smaller
rows of random letters
used to test distance
vision
Each row is designated
by a number
corresponding to the
distance, in feet or
meters, from which a
normal eye can read all
the letters of the row

Snellen Chart

Picture &
Geometric
shape

Tumbling
E

Landolt
Ring

Counting fingers : 1/60 5/60

Hand movement : 1/300
Light perception : 1/~
No light perception : total blindness

3. Pinhole Test

Refractive blurred
(myopia, hyperopia,
astigmatism)
multiple misfocused
rays entering through
the pupil and
reaching the retina
Only a few centrally
aligned focused rays
will reach the retina,
resulting in a sharper
image

4. The Confrontation Visual Field Test

The patient is seated facing

the examiner with one eye
covered while the examiner
closes the opposite eye
In this way, the examiners
normal field of vision
corresponds to the patients
and serves as the comparison
for the test.
The examiner then presents 1
to 4 fingers in each of the 4
quadrants of the visual field
and asks the patient to report
the number of fingers being
shown without looking
directly at them

Cornea Examination

Plasidiscope Test

Device: plasidiscope board with

concentric black and white circle.
Technique:

Source of Light behind patient

Plasidoscope as high as eyes of patient
See through space in the middle of
plasidoscope picture of patient cornea.

Interpretation:

Concentric shadow normal cornea

Oval concentric lines astigmatism
Unregulated concentric lines irreguler
astigmatism
Unclear lines unclear cornea or
edema of cornea

Cornea Reflex / Cornea Sensibility

Aim:Trigeminal nerve function test.

Technique:

Ask patient to look contrary side of examined

cornea.
Hold patient eyelid using thumb and index finger.
Cotton patched to cornea surface
See present of patient cornea reflex, pain, and
lacrimation

There is cornea reflex good sensibility

Cornea reflex decrese to patient with keratitis,
herpes simplex ulcer

Pupil examination

1. Pupil Examination

The pupils should be

symmetric, and each one
should be examined for
size, shape (circular or
irregular), and reactivity to
both light and
accommodation.
Direct response to light
refers to constriction of the
illuminated pupil
The consensual
response is the normal
simultaneous constriction
of the opposite
nonilluminated pupil

2. Extraocular Movements

Patient was asked to theirs eyeball following

movement of examiner fingers

3. The cover tests

1. The coveruncover test to

detect the presence of a squint:
Observe if one eye is preferred for
fixation
Ask the patient to look at the fixation
target if in a child this can be a light or
toy
Occlude (for a few seconds) the eye that
appears to be fixing.
As you cover the eye, watch the other
uncovered eye to see if it moves to take
up fixation
Remove the occluder and see if the
original eye retakes up fixation. If it
does, it is the preferred fixating eye and

4. Slitlamp Examination

The slitlamp is a tablemounted binocular

microscope with a special
adjustable illumination
source attached.

A linear slit beam of

incandescent light is
projected onto the globe,
illuminating an optical cross
section of the eye

The angle of illumination can

be varied along with the
width, length, and intensity
of the light beam.

The magnification can be

adjusted as well (normally
10x to 16x power).

Additional Slitlamp Techniques

1. Lid eversion

Lid eversion to
examine the
undersurface of the
upper lid can be
performed either at
the slitlamp or
without the aid of
that instrument.
It should always be
done if the presence
of a foreign body is
suspected

2. Fluorescein test

Purpose To indentify cornea

epithelium defect

Sterile paper strips containing

fluorescein are wetted with
sterile saline or local
anesthetic and touched
against the inner surface of
the lower lid, instilling the
yellowish dye into the tear
film

The illuminating light of the

slitlamp is made blue with a
filter, causing the dye to
fluorescein

A uniform film of dye should

cover the normal cornea. If
the corneal surface is
abnormal, excessive amounts
of dye will absorb into or

Measurement of Intraocular
Pressure

Palpation

With the patients eyes closed, the examiner

places his or her hands on the patients head
and palpates the eye through the upper eyelid
with both index fingers
The test is repeated on the contralateral
eye for comparison.
A rock hard eyeball only occurs in acute
angle closure glaucoma.
Slight increases in intraocular pressure such
as occur in chronic glaucoma will not be
palpable.

Tonometry

Tonometry is the method of measuring

intraocular pressure using calibrated
instruments
The normal range is 10 to 21 mm Hg

Applanation Tonometry

The Goldmann
applanation tonometer
is attached to the
slitlamp and measures
the amount of force
required to flatten the
corneal apex by a
standard amount
The higher the
intraocular pressure,
the greater the force
required

Schiotz Tonometry

The advantage of
this method is that it
is simple, requiring
only a relatively
inexpensive, easily
portable hand-held
instrument

Gonioskopy

Gonioscopy is the method of

examination of the anterior
chamber angle anatomy using
binocular magnification and a
special goniolens.
After topical anesthesia, the
patient is seated at the slitlamp
and the goniolens is placed on the
eye
Magnified details of the anterior
chamber angle are viewed
stereoscopically.
By rotating the mirror, the entire
360-degree circumference of the
angle can be examined.
The same lens can be used to
direct laser treatment toward the
angle as therapy for glaucoma.

Direct Ophthalmoscopy
Red Reflex Examination
If the illuminating light is aligned directly along the
visual axis, more obviously when the pupil is dilated,
the pupillary aperture normally is filled by a
homogeneous bright reddish-orange color.
This red reflex, equivalent to the "red eye" effect of
flash photography, is formed by reflection of the
illuminating light by the fundus through the clear
ocular media
Any opacity located along the central optical pathway
will block all or part of the red reflex and appear as a
dark spot or shadow.
If the opacity is still moving or floating, it is located
within the vitreous (eg, small hemorrhage).

Fundus Examination
The primary value of the direct ophthalmoscope is in
examination of the fundus
evaluation of the central fundus, including the disk,
the macula, and the proximal retinal vasculature.
Pharmacologically dilating the pupil greatly enhances
the view and permits a more extensive examination of
the peripheral retina.
It is also optimized by holding the ophthalmoscope as
close to the patient's pupil as possible (approximately
1-2 inches). This requires using the examiner's right
eye and hand to examine the patient's right eye and
the left eye and hand to examine the patient's left eye

Device: oftalmoscope and drug for dilatation

of pupil (mydriacyl).
Technique:

Examine in dark room!

Prinsiple: right with right, left with left.
First, use +12.00 D of optalmoscope.
Opthalmoscope is about 10 cm from patient eye.
Move the opthalmoscope approach the eye and
change the lenticular force approach 0 D.
Light focus to the papil of optic nerve.
Evaluate all part of retina

9. Indirect Ophthalmoscopy

The indirect ophthalmoscope is worn on the

examiner's head and allows binocular viewing
through a set of lenses of fixed power.
A bright adjustable light source attached to the
headband is directed toward the patient's eye.
As with direct ophthalmoscopy, the patient is told to
look in the direction of the quadrant being
examined.
A convex lens is hand-held several inches from the
patient's eye in precise orientation so as to
simultaneously focus light onto the retina and an
image of the retina in midair between the patient
and the examiner

Specialized Ophthalmologic
Examination

Perimetry

Is used to examine the central and peripheral

visual fields.
This technique, which is performed separately
for each eye, measures the combined function
of the retina, the optic nerve, and the
intracranial visual pathway.
It is used clinically to detect or monitor field
loss due to disease at any of these locations

Color Vision Testing (Ishihara Test)

The plates are made up of

dots of the primary colors
printed on a background
mosaic of similar dots in a
confusing variety of
secondary colors
The primary dots are
arranged in simple patterns
(numbers or geometric
shapes) that cannot be
recognized by patients with
deficient color perception.
The patient should be given
a maximum of 3 s to
identify each plate.
Ishihara plate

Diagnosis of Extraocular Abnormalities

1. Lacrimal System Evaluation

Tears and their components are produced by

the lacrimal gland and accessory glands in the
lid and conjunctiva

Schrimer Test

The Schrimer test

is a simple method for assessing

gross tear production
Schirmer strips are disposable 35mm-length dry strips of filter paper
The tip of one end is folded at the
preexisting notch so that it can
drape over the lower lid margin just
lateral to the cornea
Tears in the conjunctival sac will
cause progressive wetting of the
paper strip
The distance between the leading
edge of wetness and the initial fold
can be measured after 5 minutes
using a millimeter ruler.

Interpretation

The strip is then carefully removed,and the

length of the strip that has become moistened
with tears is measured.
A normal eye should produce enough tears to
wet at least 10 mm of the strip in 5 minutes

Schrimer Test 2
This test do if in schrimer test 2 be found that
wet strip less than 10 mm after 5 minute
1. On one of eye are droped topical anesthesia
and give schrirmer paper.
2. Do nose stimulation with cotton during 2
minute
3. In normal condition, filter paper will wet
15mm after 5 minute.

2. Exophthalmometry

A method is needed to
measure the
anteroposterior location of
the globe with respect to
the bony orbital rim
The lateral orbital rim is a
discrete, easily palpable
landmark and is used as the
reference point
The distance from the
cornea to the orbital rim
typically ranges from 12 to
20 mm, and the two eye
measurements are normally
within 2 mm of each other

Abnormal protrusion of one or both eyes is

called proptosis (or exophthalmos). Proptosis
is caused by an increased mass in the orbit
behind the globe. Because the bony orbit is
rigid, any increase in the volume of its
contents will push the globe forward.

3. Ultrasonography

Ultrasonography utilizes the

principle of sonar to study
structures that may not be
directly visible
It can be used to evaluate
either the globe or the orbit
High-frequency sound waves
are emitted from a special
transmitter toward the target
tissue
As the sound waves bounce
back off the various tissue
components, they are
collected by a receiver that
amplifies and displays them
on an oscilloscope screen

Ophthalmic Radiology (X-Ray, CT Scan)

Plain x-rays and CT scans are useful in the

evaluation of orbital and intracranial
conditions. CT scan in particular has become
the most widely used method for localizing
and characterizing structural disease in the
extraocular visual pathway.
The intraocular applications of radiology are
primarily in the detection of foreign bodies
following trauma and the demonstration of
intraocular calcium in tumors such as
retinoblastoma.

Magnetic Resonance Imaging

The technique of magnetic resonance imaging

(MRI) has many applications in orbital and
intracranial diagnosis.
Improvements such as surface receiver coils
and thin section techniques have improved
the anatomic resolution in the eye and orbit.

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