Anatomic Order of Exam.
Findings to look for.
Use low magnification and diffuse illumination with white light and a broad beam.
low magnification and diffuse illumination with white light.
- Also known as STYE.
- Is an acute inflammation in the area of a Zeis gland of the anterior lamella of the eyelid.
- Also known as an ACUTE CHALAZION.
- Is an acute inflammation in the area of a meibomian gland of the posterior lamella of the eyelid.
- Examination of an internal hordeolum requires eversion of the eyelid.
- Is a subacute or chronic granuloma with low-grade inflammation from surrounding lipid resulting from a blocked sebaceous gland.
- Is an acute abscess of an eyelash follicle rather than a sebaceous gland and is nearly always caused by staphylococcal infection.
- Thin, honey-colored flakes (collarettes) among eyelashes.
- Long standing staphylococcal infection is associated with loss (madarosis), whitening (poliosis) or misdirection (trichiasis) of eyelashes.
Dandruff-like flakes or accumulations of oily sebaceous material among eyelashes.
- Caused by a mite.
- Especially common in elderly patients.
- Associated with little or no inflammation. - Presence of waxy-appearing, cylindrical cuffs (hypertrophic follicular epithelium) around the bases of eyelashes.
- Requires ophthalmologist or plastic surgeon care if involving.
- Lid margin / gray line.
- Tear duct mechanism.
- Tarsal plate or levator muscles .
Can be examined by eyelid eversion.
Can be affected by:
-Tiny, domed shaped nodules that form in response to any subacute or chronic inflammation.
-Consist of central core of hyperemic blood vessels that protrude up and perpendicular to the tarsal plate, surrounded by edema and inflammatory cells.
- Fibrous septa constraint the tissue from swelling diffusely and evenly thus causes a "bumpy appearance" on the conjunctiva
- Much larger than papillae.
- Are consist of masses of lymphocytes, lymphoblasts and a few macrophages.
- Do not contain vascular core.
- Dome-shaped elevations upward from conjunctival surface such that normal blood vessels are also pushed upward so that they run up onto the surface of each follicle.
- Mainly caused by Chlamydia, adenoviruses, herpes simplex (primary infection), molluscum contagiosum, and reactions to topical ophthalmic medication.
- Caused by cat scratch disease in most cases.
MEMBRANES & PSEUDOMEMBRANES.
- Caused by adenoviruses, herpes simplex (primary infection), Chlamydia (infants), b-hemolytic Streptococcus, chemical burns and Erythema multiforme.
- Ocular diphtheria is associated with pseudomembrane formation.
- Often lodged in the palpebral conjunctiva of the upper eyelid
- A loose eyelash occasionally becomes trapped in the punctual orifice.
Can be affected by:
CILIARY (LIMBAL) FLUSH
- Indicates corneal, episcleral, scleral or intraocular inflammation.
- Hyperemia of anterior ciliary blood vessels form a red to violaceous perilimbal ring (1-2 mm in radial pattern) of dilated blood vessels.
- Usually indicate verneal of atopic conjunctivitis.
- Same structure and appearance as palpebral papillae.
- Occurs with chlamydial infections or toxic follicular reactions to topical ophthalmic medications.
Can be affected by:
SECRETIONS & DISCHARGE.
- Edema of the conjunctiva characterized by diffuse swelling (bulbar conjunctiva lacks anchoring septa), most prominent in the area of the palpebral fissure where the pressure of the eyelids does not restrict the swelling.
- Most often caused by allergy but can be caused by other inflammatory conditions such as conjunctivitis, episcleritis, scleritis, uveitis, endophthalmitis and orbital cellulitis.
- Increased flow and dilatation of blood vessels in the conjunctiva usually most prominent peripherally and tending to fade as the limbus is approached.
- Nonspecific finding that can occur with practically any ocular inflammation, dryness, or environmental irritants.
EPITHELIAL DEFECTS & ULCERS.
- Stains with fluorescein
and scleral abnormalities can be observed even with a penlight. Recall that
the episclera and sclera have a separate blood supply from that of the conjunctiva.
Conjunctival hyperemia has a red appearance with finer, less tortuous vessels
whereas the deeper episcleral and scleral hyperemia is often violaceous.
Massaging directly with a cotton swab can move the conjunctival vessels
but not the deeper vessels. Topical vasoconstricting agents affect conjunctival
vessels much more than those deeper.
- Typically short lived, benign course and is immunologically mediated inflammation, related to allergy.
- Can be diffuse, sectorial or nodular.
- No ciliary pain.
- No flare or cell in the anterior chamber.
Associated with detectable systemic disease in about 50% of affected patients.
- Most common cause is autoimmune collagen-vascular disease, granulomatous diseases such as syphilis or tuberculosis, or gout or hyperuricemia.
- Can cause damage in the form of scleral thinning and complications of uveitis including glaucoma.
- Can be diffuse, sectorial nodular or necrotizing.
- Visual acuity is slightly reduced.
- Deep hyperemia.
- Ciliary pain (or at least photophobia).
- Often flare and cell in the anterior chamber.
- Ciliary (limbal) flush
DEFECTS AND ULCERS._____________
-Best seen with the aids of stains.
- History of trauma.
- Foreign body sensation.
- Accumulations of inflammatory cells on the corneal endothelium that occur with intraocular inflammation.
- Variable in size and can be punctate, round or stellate.
- Most often seen on the inferior or central cornea.
- Can become hylanized (clear), or become pigmented following inactivation of inflammation.
- Causes the stroma or epithelia to become more relucent and silvery and thus taking on a steamy appearance.
- Associated with acute angle-closure glaucoma, dystrophy, inflammation or trauma.
- Can be screened with an optical section slit lamp beam at an angle of 60 degrees directed onto the peripheral cornea just inside the limbus. The chamber is considered to be shallow if the distance between the corneal endothelium and the surface of the iris is less than one fourth the thickness of the cornea.
- Tonometry may be used to evaluate suspected glaucoma. Goldmann applanation tonometry is a more accurate method than Schiotz tonometry.
FLARE AND CELL.___________________
- Flare refers to the visibility of the slit lamp light beam as it passes through the aqueous humor in the anterior chamber. This occurs when the protein content increases due to intraocular inflammation.
- Inflammatory cells when present can be seen as "white dots", rising and falling in the convection currents of the anterior chamber.
- Blood in the anterior chamber layering inferiorlyUsually from trauma.
- Purulent (neutrophilic) exudates in the anterior chamber usually white to yellow material layering inferiorly.
- Usually seen with corneal or intraocular infections or with Behcet's disease.
- Autoimmune disorder (Juvenile rheumatoid arthritis, ankylosing spondylsis, Reiter's syndrome, inflammatory bowel disease, psoriasis).
- Infections (Syphilis, TB, Herpes Zoster, Herpes Simplex, Adenovirus).
- Malignancy ( Masquerade syndrome-Retinoblastoma, Leukemia, Lymphoma, Malignant melanoma,).
- Vision becomes gradually blurred.
- Mild to marked pain.
- Slight to marked photophobia.
- Diffusely red with slight to marked circumcorneal flush.
- Small and irregular shape if posterior synechiae are present.
- Keratic precipitates on posterior surface of cornea.
- Flare and cell in the anterior chamber can be seen with the slit lamp.
- Course may be acute or chronic.
- Recurrences are common sometimes.