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Anatomy, Physiology,& Examination of the Eye

Hariyah M. Mahdi, MD.Ophth.

Department of Ophthalmology

Medical Faculty Brawijaya Univ.

/ dr.Saiful Anwar Hospital 1


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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.

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ANATOMY of the EYE

Orbita

Eye Ball:

- The wall & content of the eye Extraocular muscle

Adnexa

Lacrimal apparatusOptic nerve / N.II

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ORBITA

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The

Human

Eye

reousHumor

Lens

AqueousHumor

Pupil

Iris

Ligaments

Lens Muscle

eyelid

Cornea

Retina

Blind Spot

Optic Nerve

Fovea

ChoroidSclera

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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 nerveOptic chiasm

Visual tract

Occipital lobe

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Visual pathway

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Ocular Examination Routine Examination

General InformationEvery 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 introduceour self and obtain permission for examining the patient.21


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Symptoms & Signs: 5 Categories1. Subnormal Visual acuity

2. Pain or discomfort

3. Change of appearance of lids, orbit, or eye4. Diplopia or dizziness

5. Discharge or increased conjunctival secretion

Continued

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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 eyeF. Used medication

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Basic Examination

Visual Acuity: central and periphery

Central Visual Acuity:

natural and with correctionWith Snellen chart, E chart, Landorp ring

Finger counting

Hand movement Light Perception

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Peripheral vision

The function of peripheral retina

Examination with:

-Confrontation test.

- Tangenscreen.

- Perimetry.

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Examination of the external part of the eye

Must be Systematical (Star t ing w ith inspect ion)

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 asloupe ; 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 notto the sides (fig 3B).

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3. Close the eyelids together placing the superior palpenra over the

inferior one. (fig 3C)

4. Place the edge of pointing finger over the superior tarsus and press it

downward (fig 3D).

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5. 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 METHODBasic:

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 procedure2. 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. Ask patient to look at ceiling or his own finger placed in front of the eye.

6. Place the base of tonometer on the central cornea.

7. After acquiring a stable reading on the scale, record the reading (between

0-15).

8. 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. 61


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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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4. 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.

5. 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

OrWidest 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

OnchocerciasisLeprosy

Cataract

Herpes simplex keratitis

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Posterior segment disease

GlaucomaRetinal 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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