This document provides an overview of how to examine the eye through external examination of the iris, pupil, and lens, as well as fundus examination and assessment of visual fields and intraocular pressure. Key steps covered include inspection of iris color and patterns, evaluation of pupil size, shape and reactivity, and examination of lens position, shape, color and transparency. Fundus examination techniques like ophthalmoscopy are outlined along with assessing structures like the optic disc, macula, blood vessels and general retina for abnormalities. The document concludes with a thank you.

1. Examination of
Eye
-RESHMA ANN MATHEW

2.  External Examination of eye
 Fundus Examination
 Visual field examination

3. External Examination
 Examination of-
• Iris
• Pupil
• Lens
 Intra-ocular pressure (IOP)

4. Examination of IRIS
 COLOUR –
 Light blue or green in Caucasians and Dark brown in
orientals
 Heterochromia iridium- different colour
of 2 iris
 Heterochromia iridis-different colour of sectors of the
same iris
It occurs due to involved iris being lighter or darker than the
normal

5.  Iris lighter than normal-
• congenital heterochromia,
• atrophic patches in chronic uveitis,
• metastatic carcinoma

6.  Iris darker than normal-
• Iris naevi-appear as freckles
• ocular melanocytosis,
• haemosiderosis,
• siderosis bulbi,
• retained iris foreign body,
• malignant melanoma of iris
• lymphoma

7.  PATTERN OF NORMAL IRIS
o Pattern occurs due to presence of collarette, crypts and radial
striations on its anterior surface
o It is disturbed in
i. Acute iridocyclitis-muddy iris
ii. Healed iridocyclitis-atrophy of iris
 PERSISTENT PUPILLARY MEMBRANE
o It is seen as abnormal congenital tags of iris tissue
adherent to the collarette area

8.  SYNECHIAE
o It is the adhesion of iris to other intraocular structures
o Types-
i. Anterior- in Adherent leucoma
ii. Posterior- in Iridocyclitis; can be total, annular or segmental
 IRIDODONESIS
o It is the tremulousness(trembling) of the iris
o Seen in aphakia and subluxation of lens (since posterior
support is lost)

9.  NODULES ON THE IRIS SURFACE
o Seen in granulomatous uveitis, melanoma,
tuberculoma and gumma of iris
 RUBEOSIS IRIDIS
o New vessel formation on the iris
o Seen in diabetic retinopathy, central retinal vein occlusion,
chronic uveitis, chronic retinal detachment, retinoblastoma

10.  GAP OR HOLE IN THE IRIS
o May be due to congenital coboloma or due to iridectomy(surgical
coboloma)
o Iridodialysis-separation of iris from ciliary body
 ANIRIDIA OR IRIDEREMIA
o Complete absence of iris
o Rare congenital condition
 IRIS CYST
o In patients using strong miotic drops, it may be seen
in the pupillary margin

11. Examination of PUPIL
 NUMBER
o Normal: 1 pupil
o Rarely: more than 1 pupil (polycoria)
 LOCATION
o Normal: almost centre of the iris, slightly nasal
o Rarely: congenitally eccentric (corectopia)
 SIZE
o Normal: 3-4mm depending upon illumination
o It may be abnormally small (miosis) or large(mydriasis)
o Anisocoria- It is a condition where there is difference
between the size of two pupils

12. o Causes of Miosis
• Effect of local miotic drugs-Parasympathomimetic drugs
• Iridocyclitis-narrow, irregular, non-reacting pupil
• Head injury-pontine haemorrhage
• Senile rigid miotic pupil
• Due to effect of strong light
• During sleep pupil is pinpoint

13. o Causes of Mydriasis
• Effect of topical sympathomimetic drugs-Adrenaline,
phenylephrine
• Effect of topical parasympatholytic drugs-Atropine,
homatropine, tropicamide, cyclopentolate
• Acute congestive glaucoma
• Absolute glaucoma

14.  SHAPE
o Normal: circular
o Irregular narrow- iridocyclitis
o Festooned- effect of mydriatics on posterior
segment synechiae
o Vertically oval/pear shaped/updrawn- postoperatively (due to
incarceration of iris or vitreous in the wound at 12 o’clock postion)

15.  COLOUR
o Normal: greyish black
o Aphakia-jet black
o Immature senile cortical cataract-greyish white
o Mature cortical cataract-pearly white
o Hypermature cataract-milky white
o Cataracta brunescens-brown
o Cataracta nigra-brownish black
o Leucocoria-white reflex in pupil
o Glaucoma-greenish hue
o Iridocyclitis-dirty white exudates

16.  PUPILLARY REACTIONS
o Direct light reflex-
Normal: pupil reacts briskly and constricts
o Consensual light reflex
Normal: contralateral pupil should also constrict

17. o Swinging flash light test-(when RAPD is suspected)
• Normal: both pupils constrict equally and the pupil to which
light is transferred remains tightly constricted
• RAPD present: affected pupil will dilate when flash light is
moved from normal eye to abnormal eye. This is called
Marcus Gunn Pupil
o Near reflex- Pupil constricts while looking at a near object

18. Abnormal pupillary reactions are seen in
i. Amaurotic pupil
ii. Efferent pathway defect
iii. Wernicke’s hemianopic pupil
iv. Marcus Gunn pupil
v. Argyll Robertson pupil
vi. Tonic pupil

19. Examination of LENS
 Can be examined using oblique illumination, slit lamp
biomicroscopy and distant direct ophthalmoscopy with FULLY
DILATED PUPILS
 POSITION
o Normal: patellar fossa by the zonules
o Dislocation of lens: lens not present in its normal position
i. Anterior dislocation-present in anterior chamber
ii. Posterior dislocation-present in vitreous cavity either
floating(LENSA NUTANS) or fixed to the retina(LENSA
FIXATE)

20. o Subluxation of lens-lens is partially displaced from its position
• Causes-trauma, marfan’s syndrome, homocystinuria
o Aphakia-absence of lens
• It is diagnosed by
i. jet black pupil, deep anterior chamber, empty patellar fossa by slit
lamp biomicroscopy
ii. hypermetropic eye on ophthalmoscopy, retinoscopy
iii. ABSENCE of 3rd and 4th purkinje images
o Pseudophakia-
• When posterior chamber IOL is present, it is diagnosed by black
pupil, deep anterior chamber, shining reflexes (from anterior surface of
IOL) and PRESENCE of all the four Purkinje images

21.  SHAPE
o Normal: biconvex structure, on slit lamp-optical section shows
embryonic, foetal, infantile and adult nuclei, cortex and capsule
o Spherophakia-spherical
o Lenticonus anterior-anterior cone shaped bulge (Alport
syndrome)
o Lenticonus posterior-posterior cone shaped bulge
o Coloboma of lens-Notch in the lens

22.  Colour
o Normal: In young age, it is almost clear or gives a faint blue hue
o Old age-greyish white (mistaken to be cataract)
o CORTICAL cataract- greyish white (immature), pearly white
(mature), milky white (hypermature)
o NUCLEAR cataract-amber, brown or black
o Cataractous lens with siderosis bulbi-rusty (orange)

23.  TRANSPARENCY
o Normal: transparent
o Any opacity in the lens is called CATARACT
o Complicated cataract-breadcrumb appearance (polychromatic
lustre)
o True diabetic cataract-snow flake opacities
o Wilson’s disease-sunflower cataract
o Concussion injury of lens-rosette shaped cataract

24.  DEPOSITS ON ANTERIOR SURFACE OF LENS-
o Vossius ring-in blunt trauma
o Pigmented clumps-iridocyclitis
o Dirty white exudates-uveitis, endophthalmitis
o Rusty deposits-siderosis bulbi (deposition of ferrous ions)
o Greenish deposits-chalcosis(deposition of copper ions)

25.  PURKINJE IMAGES TEST
o It WAS used to diagnose mature cataract and aphakia
o Normal-
• When a strong beam of light is shown to the eye,
4 images (purkinje images) are formed from the
four different reflecting surfaces [ant & post
surfaces of cornea and lens]
o Mature cataract-4th image is absent (post surface of lens)
o Aphakia-3rd and 4th are absent (ant & post surface of lens)

26. Intraocular pressure
 Digital tonometry-
o IOP raised-fluctuation produced is feeble or absent, eyeball-firm to hard
o IOP low-eyeball-soft
 Indentation and Applanation tonometers are frequently used
 Normal IOP=10-21mm Hg
 Hypotony- IOP < 10mm Hg
• Causes-ruptured globe, retinal/choroidal detachment, postoperative wound
leak
 Glaucoma suspected when IOP>21mm Hg

27. Fundus Examination
 To diagnose diseases of vitreous, optic nerve head, retina and choroid
 For thorough examination, pupils to be dilated with 5%phenylephrine and/or
1%tropicamide eye drops

28. Techniques of Fundus Examination
1) Ophthalmoscopy
a) Distant direct ophthalmoscopy
b) Direct ophthalmoscopy
c) Indirect ophthalmoscopy
2) Slit lamp bio-microscopic examination by
a) Indirect slit lamp bio-microscopy
b) Hruby lens bio-microscopy
c) Contact lens bio-microscopy

29.  OCULAR MEDIA
o Normal- transparent
o Opacities-black against red glow (distant direct
ophthalmoscopy)
• Causes-corneal opacity, lenticular opacity, vitreous opacity

30.  OPTIC DISC
o SIZE: normal-1.5mm; hypermetropes-smaller;
myopes-larger
o SHAPE: normal-circular; high astigmatism-oblong
o MARGINS: normal-well defined; blurring of margins-
papilloedema, papillitis
o COLOUR: normal-pinkish with central pallor;
Hyperaemia-papilloedema
Pale-partial optic atrophy
Chalky white-primary optic atrophy
Yellow waxy-consecutive optic atrophy

31. o CUP DISC RATIO: Normal-0.3;
Large cup-physiological or glaucomatous;
Cup full-papilloedema, papillitis
o SPLINTER HAEMORRHAGES: seen in primary open
angle glaucoma, papilloedema
o NEOVASCULARISATION: diabetic retinopathy
o PERIPAPILLARY CRESENT: myopia

32.  MACULA
o Situated at posterior pole with its centre (foveolar) about 2 disc diameters
lateral to temporal margin of disc
o Normal-slightly darker than surrounding retina, its centre imparts a bright
reflex-foveal reflex
o Abnormalities-
• MACULAR HOLE
• MACULAR HAEMORRHAGE
• CHERRY RED SPOTS- Neimann Pick’s disease, Gaucher’s disease,
central retinal artery occlusion
• MACULAR OEDEMA- trauma, intraocular operations

33. • PIGMENTARY DISTURBANCES- after trauma, solar burn, chloroquine
toxicity
• BULL’S EYE MACULAR LESIONS- age related macular degeneration,
chloroquine retinopathy
• HARD EXUDATES-hypertensive retinopathy, exudative diabetic
maculopathy
• MACULAR SCARRING- trauma, disciform macular degeneration

34.  RETINAL BLOOD VESSELS
o Normal: arterioles-bright red, veins-purplish
o Abnormalities-
• NARROWING OF ARTERIOLES-hypertensive retinopathy,
arteriosclerosis, central retinal artery occlusion
• TORTUOSITY OF VEINS-diabetes mellitus, central retinal vein
occlusion
• SHEATHING OF VESSELS-hypertensive retinopathy
• VASCULAR PULSATIONS- venous pulsations (seen normally in some),
arterial pulsations ( seen in patients with aortic regurgitation, aneurysm,
exophthalmic goitre)

35.  GENERAL BACKGROUND
o Normal-pinkish red
o Abnormal-
• SUPERFICIAL RETINAL HAEMORRHAGES-hypertension, diabetes,
trauma
• DEEP RETINAL HAEMORRHAGES-diabetic retinopathy
• COTTON WOOL SPOTS(SOFT EXUDATES)-
hypertensive retinopathy, diabetic retinopathy,
anaemias, collagen disorders
• HARD EXUDATES-Hypertensive retinopathy,
diabetic retinopathy
• COLLOID BODIES-senile macular degeneration
• PIGMENTARY DISTURBANCES-retinitis pigmentosa

36. • MICROANEURYSMS-diabetic retinopathy
• NEOVASCULARISATION of retina- diabetic retinopathy, sickle cell
retinopathy
• TUMOURS of fundus-retinoblastoma
• PERIPHERAL RETINAL DEGENERATION
• RETINAL HOLES
• PROLIFERATIVE RETINOPATHY
• RETINAL DETACHMENT

37. THANK YOU