Conjunctiva clinical pictures

 

This some clinical pictures of conjuctival diseases in the eye that arranged  in asimple manner

 

CONJUNCTIVA:

1-1RY PTERYGIUM
2-RECURRENT PTERYGIUM
3-VASCULAR PTERYGIUM
4-PINGUECULA
5-SYMBLEPHARON

6-SUBCONJUNCTIVAL HEMORRHAGE
7- CONJUNCTIVAL INJECTION
8-CILIARY INJECTION
9-BITOT SPOTS
10-CONJUNCTIVAL BLEB: (SUBSCLERAL TRABECULECTOMY)

Cataract Classification

 

This is simple classification of clinical cataract according to "onset , Truma and Age"

differential diagnosis

differential diagnosis

 

These is some differential diagnosis of Ophalmology diseases

 

A- Tremulus Iris

1- HYPERMATURE CATARACT

2- APHAKIA

3-POSTERIOR LENS DISLOCATION

4 SUBLAXATION OF LENS

5- CONGENITAL GLAUCOMA

 

B- Serpiginous Ulcers

1- HYPOPYON ULCER (acute )

2- FASCICULAR ULCER ( chronic ) of phlyctenular conjunctivitis

3- MOOREN ’S ULCER (chronic )

 

C- Cystoid Macular Edema :

1- DIABETIC MACULOPATHY

2- CENTRAL RETINAL VEIN OCCLUSION ( ischemic type )

3- DRUG-INDUCED BY PROSTAGLANDIN ANALOGUES AS LATANOPROST (in pseudophekics & aphakics)

 

D- Visual Impairment with Deafness :

1-ACUTE IRIDOCYCLITIS (with Vogt-koyanagi-Harada syndrome )

2- RETINITIS PIGMENTOSA (with Refsum ’ s disease )

 

E- Ring Scotoma :

1- PRIMARY OPEN ANGLE GLAUCOMA

2-RETINITIS PIGMENTOSA

Clinical lid by image

1) LIDS:

	1. CHALAZION
	2. FUNGATING CHALAZION
	3. STYE (HORDEOLUM EXTERNUM)
	4. DERMATOCHALASIS
	5. XANTHLASMA

	6. RUBBING LASHES / TRICHIASIS
	7. MADAROSIS
	8. POLIOSIS
	9. ENTROPION
	10. ECTROPION

	11. TYLOSIS
	12. PTOSIS
	13. LID RETRACTION

Test for angle of manifest squint and Cover-uncover test

Corneal reflection test(Hirschberg test)=Test for angle of manifest squint:

Aim: to test the angle of manifest squint roughly

Steps:

1)-Place a light source in front of of the patient at a distance of 50 cm (just in front of your nose)

2)-The patient is asked to look at this source of light

3)-Observe the position of the corneal light reflection which indicates the angle as follow:

Results:

- In the center of the pupilà0 degree.

-At the papillary marginà10 -15 degrees.

-Midway between the center of the pupil & the limbusà 20 -25 degrees.

-At the limbusà 40 degrees.

-Outside the limbus àeach 1mm =8 degrees + 40 ).

Oral questions:

*How to test for the angle of squint accurately

*What is the types & significance of measurement of angle of squint

*How to test the angle of latent squint

 

Cover-uncover test

Aim: it differentiates between unilateral & alternating concomitant squint.

Steps: The test is done in 3 steps:

1)-The patient is asked to fix a small object(finger or pen) at a distance of 50 cm & the eyes are observed to determine the fixing eye & the squinting eye, then

2)-A cover( piece of paper or your hand )is used to cover the fixing eye àthe originally squinting eye will move to fix the object ( & the originally fixing eye , under the cover ,will squint.

3)-When the cover is removed ,one of 2 possibilities may happen:

*The original state before the test is regained & the other fixing eye returns rapidly to the squinting positionà unilateral squint.

*The other fixing eye (which was previously squinting) continues to fix à alternating squint.

Oral questions:

*What are the types of cover test

*What are the fallacies of cover-uncover test

Ocular motility(movements)test

Ocular motility(movements)test:

Aim: to test the ocular motility & the actions of extra ocular muscles

Methods:

a)-Following movements(center in area 18): Binocular(test conjugate movements=versions of both eyes together) then uni-ocular(test ductions of each eye separately)

b)-Order(command)movements (center in area 8)

Steps:

a)-Following movements:

1)-Place your finger (or pen) 30-50 cm in front of the patient

2)-Ask him to follow the movements of your finger

3)-Move your finger in 6 cardinal positions:

i)-Binocular

*Start from 1ry positionàUp & right then return to 1ry position then,

*Start from 1ry positionàdirectly to the right then return to 1ry position then,

*Start from 1ry positionàdown & right then return to 1ry position then,

*Start from 1ry positionàUp & left then return to 1ry position then,

*Start from 1ry positionàdirectly to the left then return to 1ry position

*Start from 1ry positionàdown & left then return to 1ry position .

ii)-Uni-ocular

*Start from 1ry positionàUp & out then return to 1ry position then,

*Start from 1ry positionàdirectly out then return to 1ry position then,

*Start from 1ry positionàdown & out then return to 1ry position then,

*Start from 1ry positionàUp & in then return to 1ry position then,

*Start from 1ry positionàdirectly in then return to 1ry position then,

*Start from 1ry positionàdown & in then return to 1ry position .

b)-Order(command)movements:

1)-Place your finger (or pen) 30-50 cm in front of the patient

2)-Order him to move his eyes in 6 cardinal position (No movement of the examiner's hand at all)

Results:

Regarding Following movements:

*There is normal ocular motility in all directions (bi- & uni-)

*There is limitation of ocular motility (e.g. up & out or down ) uniocularlyàmeans (paralytic squint)or binocularly(e.g. up & right)àmeans loss of conjugate movement.

Regarding order movements:

*There is normal ocular motility in all directions or

*There is loss of ocular motility up & out or down & out etc..

Oral questions:

*How to test for S.R action or I.O action or….

*Extra-ocular muscles(actions,nerve supply,cardinal position…)

*Limitation of ocular motility lost in paralytic squint intact in concomitant squint

Confrontation test

Confrontation test

Aim: rough method to measure gross defects in the visual field by comparing visual fields of the patient with that of the examiner.

Steps:

1)-While sitting 1 meter in front of the patient ask him to cover his right eye with his hand

2)-Cover your left eye

3)-Catch a white object in your right hand then move it from ouside inwards(in 4 directions: NasalàUpwardàdownward àtemporal)

4)-Ask the patient to tell you if he no longer see the objectàSo there is a field defect in this direction

5)-Use other coloured objects(Red,Green,Blue)

Oral questions:

*Normal limits of the visual field

*Accurate methods of measurement of the visual field

*Types of visual field defects & their importance.

Pupillary light reflex test

Pupillary light reflex test

Aim: to test all parts of the reflex pathway especially the function of the retina & optic nerve.

Steps:

1)- Must be done in dark room

2)-Place the patient's right hand vertically over the nose & foreheadàto avoid stimulation of the pupil of the other eye by direct light

3)-Apply the source of light close to the patient's left eye using your right hand

4)-Observe miosis in the same eye(direct light reflex) & in the other eye(Indirect light reflex)

5)-The same steps are done for the other eye(use your left hand for the patient's right eye)

Results:

*The light reflex is intact directly & indirectly in both eyes(in normal persons)

Oral questions:

*Pathway of the papillary light reflex

*Pupil(Causes of miosis & mydriasis, abnormal papillary reactions)

*Visual pathway

Distant Visual acuity tests:

Distant Visual acuity tests:

In all tests of V.A, one eye is tested & the other is covered.

1)-Distant vision acuity charts:(e.g. Landolet's chart or Snellen's chart)

Landolet's chart is formed of 7 rows of broken rings with their openings in different directions.(6/60, 6/36, 6/24, 6/18, 6/12, 6/9, 6/6)

Aim: Measure V.A from 6/6 up to 1/60

Steps:

*The patient is at 6 meters from the chart

*Ask the patient about the direction of the ring's opening starting from the upper most line (6/60)downwards up to (6/6)

*When the patient can not see the largest ring (6/60) at a distance of 6 meters, move him 1 meter nearer to the chartàif he can see it the V.A is 5/60 & so on (4/60, 3/60,2/60 1/60).

If he can not see the largest ring at 1 meter à CF test must be done

2)-Counting fingers(C.F):

Ask the patient to count the doctor's fingers at different distances( CF_75cm then CF_50cm then C.F_25cm). If he can notàHM test must be done

3)-Hand Movements(H.M):

*Explain the test to the patient at 1^st(when the hand moves & when stops),then

*Ask the patient to tell you about the movement of your hand which is present about 25cm from his face.

*The movement of the hand must be slow.

If the patient can not see the hand movementàP.L test must be done

4)-Perception of light(P.L):

*Must be done in dark room.

*The source of light must be held immediately in front of the eye

*Explain the test to the patient at 1^st(This is light & this is no light),then

*Ask the patient to tell you if he can perceive light(P.L) or not(No.P.L)when the source of light is in front of the eye or when withdrawn (No switch on or switch off of the torch)

Oral questions:

*V.A testing is a test of (Form sense)

*Also there are (near vision charts) at 33 cm(near point in normal persons)

*What is the meaning of (6/18 or 6/24 etc..) = patient / Normal person *The idea of the V.A Charts: is if the 2 ends of a broken ring are seen as 2 separate pointsàthis means that the rays passing through the 2 ends make a visual angle ≥ 1 minute at the nodal point of the eye & stimulate 2 cones with one unstimulated cone in between at the macula(if the angle is < 1minute the 2 ends can not be seen)

Light projection test

Light projection test

Aim: to test the function of the retinal periphery in patients with opaque media(e.g. cataract patients before cataract operation) because the fundus can not be seen in these patients

Steps:

1)-Be sure that visual acuity is at least (P.L)àif No.PLàno need for this test

2)-The test must be done in dark room.

3)-One eye is tested & the other is covered.

4)-Fall the light on the eye from a distance of(30-50 cm) from 4 directions (upwards, downwards, temporally & nasally) then ask the patient to point to the direction of light.

N.B. you may explain to him at 1^st

Results:

*Accurate projection of light in all directions

*Inaccurate projection of light in all directions

*Inaccurate projection of light in certain direction/s

Oral questions:

*Value of the test

*What the difference between (projection of light) & (perception of light)

*How to test the center of the retina(macular function)

* What are the functions of the macula

Colour sense is tested by colour perception test in eyes with opaque media(by ophthalmoscope or by coloured filters + source of light or by Maddox rod) or Ishihara book in eyes with clear media.

Form sense is tested by visual acuity testing.

Pupillary reaction: tested by papillary light reflex

Measurement of IOP(Digital method)

Measurement of IOP(Digital method)

Aim: to test the IOP roughly

Steps:

1)-Ask the patient to look downward

2)-Fluctuate the eye using 2 index fingers close to each others & above the tarsus (fluctuation means pressure with one finger & receive with the other)

3)-Compare the tension with the other eye

Oral questions:

*Accurate methods of measurement of IOP

*Normal IOP & diurnal variation

*The term (Tension) or (Pressure) is more better

*Glaucoma

Corneal sensation test= Corneal reflex test= Blinking reflex

Corneal sensation test= Corneal reflex test= Blinking reflex

Aim: to test the sensation of the cornea or blinking reflex

Steps:

1-Make the end of a piece of cotton in the form of a tapered thread(avoid to show it to the patient)

2-Ask the patient to look in the opposite direction to disturb his attention(e.g. ask him to look to his right side if you want to test his left eye & the reverse)

3-Try to touch the patient's left cornea by your right hand (& the reverse)

Results:

*Closure of eyelids(Blinking)à Intact corneal sensation or corneal reflex pathway

*No closure of eyelidsàlesions affecting any part of the reflex pathway

Reflex pathway:

Receptorsà touch receptors in the cornea

Afferent: long ciliary nsànasociliary nàophthalmic division of 5^th nerve

Center: area 18 in occipital lobe

Efferent: 7^th nerve

Effector: orbicularis oculi muscle

Action : blinking or lid closure

Oral questions:

*Pathway of corneal reflex

*Causes of lost corneal reflex

*Types of blinking:

-Spontaneous: center in basal ganglia

-Reflex: center in area 18(occipital lobe)

-Voluntary: center in area 8(frontal lobe)

*What are other reflexes which have their centers in area 18.

Lacrimal gland test

1-Regurgitation test(regurge test)

Aim: detects obstruction below the lacrimal sac(mostly in NLD)

Steps:

1-Press just below the medial palpebral ligament(MPL) by the little finger or by a glass rod covered by a piece of cotton(anatomical site of lacromal sac).

*MPL becomes more exposed by outward traction of the skin at the lateral canthus.

*It is better to use the right little finger to the left sac & the reverse

2-Observe regurgitation of any discharge(e.g. watery,mucus,pus) from the lower or upper punctum= +ve regurge test . If no regurgitation= -ve regurge test

Results:

*+ve regurge: means obstruction below the lacrimal sac

*-ve regurge : means patent lacrimal passages

Oral questions:

*Site of lacrimal sac

*Causes of +ve regurge test(e.g. dacryocystitis)

*When regurge test becomes –ve with dacryocystitis

*Disadvantages of regurge test:

Not localize the site of obstruction accurately

Not differentiate between partial & complete obstruction

*Investigations of watery eye

*Dacryocystitis

 

2-Palpation of lacrimal glands:

Aim: to detect enlargement of the lacrimal glands(Normally lacrimal gland is not palpable)

Steps:

1-The patient is sitting & the examiner is standing to the patient's side (same side of the tested gland)

2-Ask the patient to look down & nasally.

3-Try to palpate the lacrimal gland by introducing your little finger (with its anterior surface upwards)between the globe & the upper outer part of the orbital margin. Use the right little finger for the right gland & the reverse.

Results:

*If palpableàenlargement of the lacrimal gland

*If not palpable: Normal lacrimal gland

Oral questions:

*Site of lacrimal glands

*Causes of lacrimal gland enlargement (unilateral & bilateral)

*What type of proptosis induced by lacrimal gland enlargement

*Approach used to remove lacrimal gland tumours.

*Is removal of lacrimal glands must induce dry eye.

lid clinical tests

1-Upper lid elevation test(Levator action test)

Aim: rough method to test for levator action (supplied by 3^rd nerve)

Steps:

1-Ask the patient to look in 1ry position

2-Press on eyebrow/s against bone firmly (to avoid the action of frontalis muscle)

3-Ask the patient to look upwards

Results:

*If there is any degree of upper lid elevationà levator action is present

*If no elevation at allàComplete loss of levator action

Oral questions:

*What is the accurate method to test levator action.

*Muscles responsible for lid elevation & related nrves

*Significance of testing levator action

*Ptosis

 

2-Lid closure test(Orbicularis action test)

Aim: to test for orbicularis oculi muscle (supplied by 7^th nerve)

Steps:

1-Ask the patient to close his eye firmly

2-Try to open his eye gently by index & thumb fingersàfeel the power of lid closure

Results:

*If the patient can not close his eye at allà Complete loss of orbicularis action(severe degree of paralytic lagophthalmos)

*If the patient can close his eye but the eyelids can be opened easily by fingersàweakness of the orbicularis action(Mild degree of paralytic lagophthalmos)

*If the patient can close his eye & the eyelids can not be opened by fingersàNormal orbicularis action

Oral questions:

*lagophthalmos

 

3-Upper lid evertion test

Aim: to examine the upper palpebral conjunctiva & upper fornix

Types of U.L evertion:

a)-Single evertion: done to show the upper palpebral conjunctiva

b)-Double evertion: done by using lid evertor or retractor to show the upper fornix

Steps of single evertion of U.L:

1-Ask the patient to look downwards

3-Put your index finger above the tarsus & your thumb below the lashes & upper lid margin(catching them)

3-Evert the upper lid by rotating the lashes & upper lid margin over the index finger

4-The index finger may be replaced by a glass rod covered with a piece of cotton

Oral questions:

*What are the normal structures seen in single evertion

* What are the possible lesions seen in single evertion

*What are the possible lesions seen in double evertion

Eight Clinical tests for eye

I)-Eyelids:

1-Upper lid elevation test(Levator action test)

2-Lid closure test (Orbicularis action test)

II)-Lacrimal system:

3-Regurgitation test(regurge test)

4-Palpation of lacrimal glands:

III)-Conjunctiva:

5-Upper lid evertion test

IV)-Cornea:

6)-Corneal sensation test= Corneal reflex test= Blinking reflex

V)-Glaucoma:

7)-Measurement of IOP(Digital method)

VI)-Tests for retinal functions:

8)-Light projection test

9)-Visual acuity tests:

a)-V.A charts:

b)-Counting fingers(C.F_25cm , CF_50cm , CF_75cm)

c)-Hand Movements(H.M)

d)-Perception of light(P.L)

10)-Pupillary light reflex test

11)-Confrontation test

VII)-Tests related to squint:

12)-Ocular motility(movements)test:

13)-Corneal reflection test(Hirschberg test)=Test for angle of manifest squint

14)-Cover-uncover test

VIII)-Others:

15)-Instillation of eyedrops

16)-Eye bandage