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# Dr/ M.

## Abd Ul-Ghaffar (MASS)

2009
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

## ‫ ﺗﺆدى ھﺬه اﻹﺧﺘﺒﺎرات ﻓﻰ ﺣﺠﺮة ﻣﻈﻠﻤﺔ‬-

‫ وﯾﻌﻠﻢ ﻗﺒﻠﮭﺎ اﻟﻤﺮﯾﺾ‬-
‫ ﺗﺨﺘﺒﺮ ﻛﻞ ﻋﯿﻦ ﻟﻮﺣﺪھﺎ‬-

I- By Charts

## Principle of Visual Acuity Charts :

 If 2-ends of broken ring made Visual Angle > 1minute  we could see 2-separate points
passing with Nodal Point & stimulating 2-cones inbetween non-stimulating cone

 If Visual Angle < 1minute  the 2 points seen as 1-point with closure of broken ring
3-Types : a - Landolt`s chart. b – Snellen`s chart c – Emarah Arabic chart

A- Landolt`s Chart
* Consist of 7-rows of broken rings ( C ) whose openings are in various directions

## * Testing each eye separately:

. If he saw the last raw  VA = 6/6
. If he saw the above one  VA = 6/9, then 6/12, 6/18, 6/24, 6/36, 6/60
* When Pt. can`t see at distance of 6m: we move him 1-meter close to chart and
. if he saw raw of 60  his VA = 5/60
. If not: move to 4/60, then 3/60, then 2/60, then 1/60
. If not of 1/60, we shift to another method: Counting Fingers
* What do you mean by 6/60 ?! 6 Pt / 60 Normal eye

## B – Snellen`s chart C- Emarah Arabic chart

Principle: as Landolt`s chart but with letters With Arabic letters, used in arabic people
of different sizes, directions. especially.
uncontrolled astigmatism, because Pt can't
see parallel lines of letter E.
١
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

.

## * Done when Pt can't see charts at 1-meter

* Start by 75cm, if Pt can count fingers  VA = CF 75cm
* If not: to CF 50cm, then CF 25cm

## III- Hand Movement (HM)

- Done when Pt. can’t count fingers at all.
- Teach Pt that your hand is now moving, and then stop movement and tell him it is now stopped
- then Test Pt, if he can detect  VA = HM

##  Done when Pt can't see HM

 At 1st Teach Pt.: this is Light and this is Darkness
. if could perceive light  VA = PL
. if not  VA = no PL / blind

## V- Light Projection Test

(Testing of Retinal Periphery)

## Time: done if vision < CF 50cm.

How: * At 1st, Do PL because if no PL  no Light projection occurs.
* To do test:
- The eye is fixed in 1ry position
- Teach Pt.: by telling him direction of light and then ask him about direction of
light or ask him to catch it.
Importance: Testing of retinal periphery when we can't see with Ophthalmoscope because
of total cataract or any opacity in media (to be sure of good retinal function
before doing cataract extraction, …)

٢
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

Center of retina
(Testing of function of Cones)

## * Form sense: determination of shapes, figures via testing visual acuity.

* Colour sense:
- Ishihara colour book.
- Spectroscope
* Visual Acuity
* ERG ect…

## (For testing Visual Field)

Time: Vision must be > CF 50 cm
How: To do the test
- Sit in front of Pt.
- Ask Pt. to close Lt eye and cover your Rt eye
- your uncovered eyes are fixing to each other
- Distance between you and Pt. is at least 1 meter
- With your index finger at distance 50-60 cm between you and Pt.,moving from outside 
inside till Pt see it
- Begin from: Up  Nasal side  Down  Temporal
- Compare the sites at when Pt. can see your finger in all directions with your own field.
Other accurate methods:
- Arc perimeter  peripheral field changes.
- Bjerrum screen  central field changes.
- Goldman perimeter  both fields

٣
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

‫ﻧﻮر ﻟﻠﻌﯿﻦ‬

## How: To do the test

1- Apply source of light to one eye and prevent light to reach the other eye by putting your hand vertically over bridge of nose
2- .Watch Direct light reflex in the same eye normally miosis occurs as long as the light is present.
.Watch Indirect light reflex in the other eye.
Pathway:
- Stimulus: Light
- Receptors: Visual receptors (Rods – Cones)
- Afferent: ON (2nd n)  Optic chiasma (1st decussation: Nasal fibers cross to reach optic tract of opposite
side & Temporal fibers pass directly into optic tract of same side)  Optic tract (2nd decussation:
Fibers leave optic tract at post 1/3 to relay in Pre-tectal nucleus of mid-brain  both EW nuclei.

## - Center: Edinger Westphal nucleus.

- Efferent: Oculomotor (3rd n)  Ciliary ganglion  Sphincter pupillae
- Effector: Sphincter Pupillae muscle.
- Response: reflex bilateral Miosis.

## NB: Consensual Light reflex: d2

Crossing of fibers in Chiasma, Midbrain

٤
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

## Principle: ( When Near object is viewed  3-related reflexes )

- Convergence: contraction of 2-MR muscles.
- Miosis: contraction of 2-Sphincter pupillae muscles.
- Accommodation: contraction of 2-Ciliary muscles.
Pathway:
- Stimulus : Blurring image
- Receptors: Visual receptors ( Rods – Cones )
- Afferent: ON  Optic chiasma (decussation: Nasal fibers cross )
 Optic tract  LGB  Optic Radiation  Occipital Cortex
 Frontal Cortex  Internal Capsule  Edinger Westphal nucleus.
- Center: Edinger Westphal nucleus .
- Efferent: Oculomotor (3rd n)  Ciliary ganglion  Sphincter pupillae m.
- Effector: 2-MR muscles & 2-Sphincter Pupillae muscle & 2-Ciliary muscles
- Response: reflex bilateral Convergence + Miosis + Accommodation

٥
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

## Site: upper antero temporal part of orbit

Normally:  not palpable
How: To do the test (Rt little finger to Rt eye)
- Ask patient to look down, nasally
- Introduce your little finger with its bulls facing upward
- Press between Upper lateral part of bony orbit & Globe: (Back  Lat. Up) (your finger opposite eye direction)

## * What are causes of enlarged palpable lacrimal gland ?!

- Tumors of lacrimal gland (mixed cell tumour)

## ‫ اﺟﻌﻞ اﻟﻤﺮﯾﺾ ﯾﻨﻈﺮ ﻟﺘﺤﺖ وﻟﺠﻮة‬-

By little finger: ‫ ﺷﺪ اﻟﺠﻔﻦ )اﻟﻠﻲ ﻓﻮق اﻟﻐﺪة( ﻷﻋﻠﻲ وﻟﻠﺨﺎرج ﺗﻠﺤﻆ ﺟﺰء ﻇﮭﺮ أﻣﺎﻣﻚ ﻓﻠﯿﺸﻲ أﺣﻤﺮ‬-

٦
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

## Site: Lacrimal Fossa in medial lower part of orbit, below MPL

How: To do the test (Rt little finger to Lt eye)
- Push lateral lid margin down and lateral till feeling MPL medially
- Press with your little finger under MPL: (back  med.) to expose lower punctum and notice any regurgitation
. If no regurgitation = -ve Regurge test
. If any regurgitation (purulent, serous, …) = +ve Regurge test

## Q- What are the lesions in lacrinial sac with -ve regurgitation ?!

- Acute dacryocystitis: d2 congestion of epithelium of canaliculi which prevent regurgitation from lacrimal sac, being very tender.
- Encysted mucocele: due to fibrous closure of the passage with accumulation of mucus inside.
- Lacrimal Fistula: because any discharge will pass first to opening of skin.

## Q- How to test Patency of lacrimal passages ?!

1- Fluorescein test: drop in conjunctival sac + cotton pellet under inferior turbinate of nose
2- Syringing e saline
3- Probing
4- Dacryocystography (plain X-ray + lipidol)
5- ENT examination

## Importance: detection of state of OO muscle & its 7th nerve

How: To do the test
1- Ask Person to close his eye firmly
2- Insert your thumb and index fingers, try to open Person`s eye gently:-
. if difficulty opened = intact of OO, 7th
. if opened easily = palsy of OO or 7th
٧
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

## Importance: Assessment of Power or Function of LPS (Thumb test) as in Ptosis

Normally: upper lid is elevated by 3-muscles: LPS, MM, Frontalis
- LPS = 3rd n.
- Frontalis = 7th n.
- MM = sympathetic n. plexus (C1, C2)
How: To do the test
- Correct Head position → Ask Pt to look down max  imum
 Fix brow against superior
 imum
orbital margin by thumb (‫ → !? ) اﻟﺪﻛﺘﻮر‬Ask Pt to look up max  Measure amount

of elevation of UL margin (in mm):
- Degrees:
Excellent Good Fair Poor
> 10 mm 7: 10 mm 4 : 6 mrn < 3 mm

- If Pt could not elevate his lid  Ptosis (complete absence of levator action)

٨
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

‫ﻗﻠﺐ اﻟﺠﻔﻦ‬

Importance:
- FB impacted in sulcus subtarsalis.
- PTDs, PTCs, Arlet`s line of Trachoma
- Follicles and Papillae.
- Membrane either true or pseudo
- Presence of Hge
How: To do the test
1- Ask Pt. to look down
2- Evert Lid by:
. Glass rod with thumb + index finger, or Only
. Your thumb + index finger
3- Index is put behind tarsus
4- Thumb holds up lashes or lid margin (the best)  pull lid Forward  evert it over your
index finger, acting as axis.
‫ إوﻋﻰ‬Press with your index on tarsus, being hard  lid can’t be everted
* Normally: in Egyptians  PTDs, PTCs and Arlet`s line: being line of fibrosis along sulcus subtarsalis 2- mm from lid margin

Q- Why Arlet’s line is present in sulcus subtarsalis: Because it is grooved, rich in BVs
Q- What is the difference () papillae of spring catarrh and trachoma

## Papillae of Spring Catarrh Papillae of Trachoma

Incidence
Gender -♀>♂ -♀=♂
Season - ↑ in summer and spring - any season
Symptoms ..Itching ..Heaviness of lid
Papillae
- Appearance -Cobble stone -Top is rounded
- Size -Larger -Smaller
- Color -Bluish white -Red
- Upper fornix -Free -Involved
Discharge ..Roby, rich in eosinophils ..Watery, inclusion bodies
(no eosinophils)
٩
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

## Normal IOP: 10-22 mmHg above atmospheric pressure.

How: To do the test
A- Digital Palpation method
- Via 2-index fingers
- We ask Pt. to look down (not to close his eyes, because contraction of muscle will ↑ its tone  false ↑ in IOP)
- Feel tension above tarsus (behind it) via pressing with finger and receiving by other finger
- Compare tension in both eyes before recording
- Finally we say: (Hard or Firm or Soft) Tension
NB:
- Don’t feel tension over tarsus being fibrous, hard.

- Here we measure Tension and not Pressure, measured via introducing needle of apparatus in the eye

## Digital method is not accurate rough, so we may use:

B- Schiotz indentation tonometer
* Schiotz has the following disadvantages: - With instrumental errors - Observer error - May be changed by changing ocular rigidity.
* Schiotz has the followIng advatnagcs: - Simple - Cheap - Portable
C- Goldman applanation tonometer
* Advantages of Applanation: - No error. - No change with ocular rigidity.
D- Tonopen
E- Airpuff Tonometer
N.B.:
A) IOP > 22mmHg is suspicious to be glaucomatous, so we do provocative tests:
1) Closed angle glaucoma: - Dark room - Mydriatic
2) Open angle glaucoma: - Priscol. - Water drinking test
B) Above 26 mmHg: Patient is sure glaucomatous
١٠
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

## How: To do the test

- The Material used and Hands of the doctor: should be clean and sterile
- Hold piece of cotton under Lower Lid (LL) of Pt. and pull LL to expose inferior fornix.
- Ask Pt. to look up
- Apply the drops in fornix, and avoid touching the eye or lash for fear of infection transmission to another person or to your eye.
* In case of suspected corneal ulcer  apply Fluorescein ED

## Q- Uses of Fluorescein in Ophthalmology:

1- Lacrimal: - Test patency of NLD
- Dry eye syndrome
- Investigation of a case of epiphora
2- Cornea: Detection of corneal ulcer, corneal fistula, FB.
3- Retina: FA of DR, CRVO, CRAO
N.B.:
- Fluorescein may carry the danger of pseudomonas infection w prefer it, so be aware of this point

١١
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

## One of the protective mechanisms to the eye.

How: To do the test (‫) أوﻻ ﺷﺘﺖ اﻧﺘﺒﺎھﮫ وﻻ ﺗﺠﻌﻠﮫ ﯾﺮى ﺣﺮﻛﺔ ﯾﺪك‬
- Twist end of piece of cotton to be a thread
- Ask Pt. to look medially and with cotton thread touch cornea without touching lashes.
Pathway:
- Receptors: touch receptors of cornea.
- Afferent: 2-long ciliary nerves (  nasociliary n  ophthalmic n  5th nerve )

## - Center: area 18/occipital cortex.

- Efferent: 7th nerve
- Effector: Orbicularis Oculi muscle
- Response: bilateral reflex closure of eye lids
- Spontaneous: Basal ganglia
- Reflex: occipital cortex 18
- Voluntary: frontal cortex 8 ‫ﯾﻐﻤﺰ‬

## Q- What are Causes of diminished or lost corneal reflex

A- Factors due to affection of receptors  hyposethia
- Corneal scarring because fibrous tissue is insensitive.
- Keratitis: herpitic keratitis (herpes simplex, herpes zoster)
- Leprosy
- Glaucoma (absolute, acute congestive)
- Local anaesthesia of ED
B- Factors due to affection of afferent and efferent nerves
- 5th nerve injury or trauma
- 7th nerve injury via tumors in pons, trauma, vascular lesion, Bell's palsy
C- Factors due to lesion in the effector organ- Due to palsy of orbicularis oculi muscle

١٢
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

Definition: abnormal ocular deviation so that the 2-visual axes are not directed towards
fixation object, one of them being deviated.
Clinical classification of Squint:- ‫ رؤف اﻟﻨﻔﯿﺲ‬/‫ھﺬه اﻟﺘﻘﺴﯿﻤﺔ ﻣﻦ أد‬

## A) Latent (Heterophoria):- ‫ﻣﺨﻔﻰ‬

1- Eso-phoria 2- Exo-phoria
3- Hypo-phoria 4- Hyper-phoria
5- In-Cyclo-phoria 6- Ex-Cyclo-phoria
B) Manifest:- ‫ﻇﺎھﺮ‬
1- False /Apparent / Pseudostrabismus ‫ﻛـﺬاب‬
2- True squint: - ‫ﺻﺎدق‬
* Incomitant (Paralytic)
* Concomitant (Hetero-tropia)
- Vertical: (Hypo-tropia – Hyper-tropia)
- Horizontal: (Eso-tropia – Exo-tropia)
- Mixed: (horizontal + vertical squint)

## Importance: rough method to measure Angle of Squint.

How: To do the test
1- Pt. is asked to look to source of light put at 50cm from him
2- The corneal reflection of light is noticed:
. Normally, point of light at Center of both Pupils
. if at Pupillary border = 10ْ -15ْ angle
. if half-way () Pupillary border and Limbus = 20ْ – 25ْ
. if at Limbus = 40ْ – 45ْ
. if on the Sclera = 7ْ are added to each 1mm away from limbus.
Measurement of Angle of Squint by: - Corneal reflection test - Arc Perimeter - Synoptophore

١٣
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ٠١٦ ٥٧٠ ١٩١٤ : ‫ ﻣـــــﺎ س‬/ ‫د‬

## The movement of globe is controlled by 6-EOMs

* 4-Recti: medial, lateral, superior, inferior.
* 2-Oblique: superior, inferior.
Actions of EOMs →

## 3-main Positions of the eye (9-Gazes/directions) 3 2 3

A- Primary position
2 1 2
B- Secondary positions
3 2 3
C-Tertiary positions

## Cardinal Directions of the Eye:

At each direction:
- only one muscle moves eye ball
- So any defect in this direction = defect in its muscle
To test Ocular Motility (2 movements),
1) Pt is asked to follow finger put at 50cm from his eye and move in all directions of gauze
Ocular movements are normal in latent and concomitant squint. Limitation of movement is
found in paralytic squint.
2) Done uniocular (Duction) then binocular (Version) by 2-methods:
A- Following movement. = F / O, 18
B- Order movement = O / F, 8
* Any defect in any direction = defect in muscle or its nerve supply  So eye is squinting in opposite direction

## * What are the Muscles acting when looking up ?!

(5- muscles) = 2-in eye: SR – IO &
3-in lid : LPS – MM – Frontalis
* How to test the function of SR ?! By asking Pt. to Look up + out at the same time
* What is the muscle acting during reading ?! SO muscle
١٤
‫ﺳﺒﺤﺎن اﷲ و ﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬ ‫د ‪ /‬ﻣـــــﺎ س ‪٠١٦ ٥٧٠ ١٩١٤ :‬‬

## ‫) ‪ (to diagnosis Latent Squint‬اﻟﻤﺨﻔﻰ‬

‫‪ -‬ﯾﺆدى ھﺬا اﻹﺧﺘﺒﺎر ﻟـ ) ﻣﺮﯾﺾ داﺧﻠﻚ وﻏﯿﺮ ﻇﺎھﺮ ﻓﻰ ﻋﯿﻨﮫ ﺣَﻮَل ‘ وأﻧﺖ ﺗﺮﯾﺪ أن ﺗﻌﺮف ھﻞ ﻋﻨﺪه ﺣﻮل ﻣﺨﻔﻰ أم ﻻ (‬
‫‪ -‬ﻏﻄﻰ أى ﻋﯿﻦ ﺛﻢ راﻗﺐ ﺣﺮﻛﺘﮭﺎ ﺑﻌﺪ إزاﻟﺔ اﻟﻐﻄﺎء‬
‫‪- Make Pt. to fix on pencil_torch putting at 50cm‬‬
‫‪- Cover one eye‬‬
‫‪- Cover is rapidly removed‬‬
‫‪- Latent squint is detected, if this eye is noticed to move to take fixation‬‬
‫‪- This mains that this eye was squinting under Cover‬‬

## ‫) ‪( to diagnosis Concomitant Squint‬‬

‫‪ -‬ﯾﺆدى ھﺬا اﻹﺧﺘﺒﺎر ﻟـ‬
‫) ﻣﺮﯾﺾ داﺧﻠﻚ و ﻇﺎھﺮ ﻓﻰ ﻋﯿﻨﮫ ﺣَﻮَل ‘ وأﻧﺖ ﺗﺮﯾﺪ أن ﺗﻌﺮف ھﻞ ھﺬا اﻟﺤﻮل ﻓﻰ ﻋﯿﻦ واﺣﺪة أم ﻓﻲ اﻹﺛﻨﯿﻦ (‬
‫‪ -‬ﻋﻤﻞ أوﻻ ً‪:‬‬
‫‪ Ocular motility test‬ﻟﻠﺘﺄﻛﺪ ﻣﻦ أﻧﮫ ‪ Concomitant squint‬وﻟﯿﺲ ‪Paralytic squint‬‬
‫‪ -‬ﻏﻄﻰ اﻟﻌﯿﻦ اﻟﺴﻠﯿﻤﺔ ‪ ،‬ﺛﻢ اﺟﻌﻞ اﻟﻌﯿﻦ اﻟﻤﺤﻮﻟﺔ ﺗﺜﺒﺖ ﻋﻠﻰ ‪...‬‬
‫‪ -‬ﻋﻨﺪ إزاﻟﺔ اﻟﻐﻄﺎء‪ :‬راﻗﺐ اﻟﻌﯿﻦ اﻟﻤﺤﻮﻟﺔ اﻟﻤﻜﺸﻮﻓﺔ ﻷى ﺣﺮﻛﺔ ‪:‬‬
‫‪ .‬إذا اﺣﻮﻟﺖ اﻟﻌﯿﻦ ﻣﺮة أﺧﺮى = ‪Unilateral Concomitant Squint‬‬
‫‪Alternating Concomitant Squint‬‬ ‫‪ .‬إذا ﺛﺒﺘﺖ ھﺬه اﻟﻌﯿﻦ واﺣﻮﻟﺖ اﻟﻌﯿﻦ اﻟﻤﻐﻄﺎة =‬

‫‪١٥‬‬
‫‪Dr / M. Abd Ulghaffar (MASS) / 016 570 1914‬‬ ‫ﺳﺒﺤﺎن اﷲ وﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬

‫‪Eye Lid‬‬
‫‪Anterior Chamber‬‬
‫اﻟﺤﺎﻟﺔ‬ ‫ﻛﯿﻒ ﺗﻌﺮﻓﮭﺎ‬
‫اﻟﺤﺎﻟﺔ‬ ‫ﻛﯿﻒ ﺗﻌﺮﻓﮭﺎ‬
‫‪1- Chalazion‬‬ ‫ﻛﯿﺲ دھﻨﻰ ﻋﻨﺪه ﻣﻦ زﻣﺎن‬
‫‪1- Hypopyon‬‬ ‫‪Pus in AC‬‬
‫‪2- Stye‬‬ ‫دﻣﻞ ﻃﺎﻟﻊ ﻣﻨﮫ ﺷﻌﺮه‬
‫‪2-Hyphaema‬‬ ‫‪Blood in AC‬‬
‫ﻗﺸﺮ أﺑﯿﺾ ﺑﯿﻦ اﻟﺮﻣﻮش ‪ +‬ﺣﺎﻓﺔ اﻟﺠﻔﻦ ﺣﻤﺮاء ‪+‬‬
‫‪3- Squamous Blepharitis‬‬ ‫‪3- AC IOL‬‬ ‫‪In case of‬‬
‫وﻟﻮ ﺳﺄﻟﺖ اﻟﻤﺮﯾﺾ‪ :‬ﺑﯿﻘﻄﻊ ﺟﻔﻨﮫ ﻣﻦ اﻟﮭﺮش‬
‫‪ICCE‬‬
‫‪4- Ptosis‬‬ ‫اﻟﺠﻔﻦ اﻟﻌﻠﻮى ﻣﺮﺗﺦٍ‬

## ‫‪6- Ectropion‬‬ ‫ﺟﻔﻦ ﻣﻘﻠﻮب ﻟﺒﺮه‬

‫‪Strabismus/ Squint‬‬
‫‪7- Lagophthalmos‬‬ ‫ﻣﺶ ﻗﺎدر ﯾﻘﻔﻞ ﻋﯿﻨﮫ‬
‫* ﻣﺸﺮوح ﺑﺎﻟﻌﺮﺑﻲ ﻓﻰ ﻣﺬﻛﺮة‬
‫‪8- Lid Retraction‬‬ ‫إﻧﺖ ﺷﺎﯾﻒ ﺑﯿﺎض ﻣﻦ ﻓﻮق اﻟﻘﺮﻧﯿﺔ‬ ‫)‪(Clinical examination‬‬

‫‪Orbit‬‬

## ‫ﺣﺐ أﺻﻔﺮ ﻋﻠﻰ اﻟﺠﻠﺪ )رﺟﻞ ﻋﺠﻮز(‬ ‫اﻟﺤﺎﻟﺔ‬ ‫ﻛﯿﻒ ﺗﻌﺮﻓﮭﺎ‬

‫‪14- Xanthelasma‬‬
‫‪1- Atrophia‬‬ ‫‪ -‬ﻋﯿﻦ ﻋﻤﯿﺎء ﺻﻐﯿﺮة ﻣﻨﻜﻤﺸﺔ داﺧﻞ‬
‫‪15- Dermatochalasis‬‬ ‫ﺟﻠﺪ ﻣﺘﺮھﻞ و زاﺋﺪ ﻣﻦ اﻟﺠﻔﻦ اﻟﻌﻠﻮى )رﺟﻞ ﻋﺠﻮز(‬ ‫اﻷورﺑﯿﺖ واﺿﺤﺔ اﻟﻤﻌﺎﻟﻢ‬
‫‪Bulbi‬‬
‫‪16- Papilloma‬‬ ‫ﺣﺎﻟﺔ ﻷول ﻣﺮة ﺗﻨﺰل ﻓﻲ إﻣﺘﺤﺎن اﻹﻛﻠﯿﻨﯿﻜﻰ اﻟﻌﺎم اﻟﻤﺎﺿﻰ‬
‫‪2- Phthisis‬‬ ‫‪ -‬ﻋﯿﻦ ﺑﺎﯾﻈﺔ ‪ ،‬زى ﻟﺤﻤﺔ ﻣﺘﺤﺮﻛﺔ ‪،‬‬
‫ﻏﯿﺮ واﺿﺤﺔ اﻟﻤﻌﺎﻟﻢ‬
‫‪Bulbi‬‬
‫‪Conjunctiva‬‬
‫اﻟﺤﺎﻟﺔ‬ ‫ﻛﯿﻒ ﺗﻌﺮﻓﮭﺎ‬

‫‪1- Pterygium‬‬ ‫‪ -‬ﻇﻔﺮة ﻣﻠﺘﺤﻤﺔ ﺷﻜﻠﮭﺎ ﻣﺜﻠﺚ رأﺳﮫ إﻟﻰ اﻟﻘﺮﻧﯿﺔ ‪ -‬إﻣﺎ‪1ry or 2ry (Recurrent) :‬‬
‫ﻣﻦ اﻵﺧﺮ ‪ :‬إﺳﺄ ل اﻟﻤﺮﯾﺾ‬
‫‪2-‬‬ ‫‪Pseudopterygium‬‬ ‫ﻣﻠﺘﺤﻤﺔ ﻣﺎﺳﻜﺔ ﻓﻰ ﻋﺘﺎﻣﺔ ﻋﻠﻲ اﻟﻘﺮﻧﯿﺔ ﯾﻤﻜﻨﻚ إﻣﺮار‪ ..‬ﺗﺤﺘﮫ‬
‫‪3-‬‬ ‫‪Pinguecula‬‬ ‫ﻣﺜﻠﺚ أﺻﻔﺮ ﻗﺎﻋﺪﺗﮫ إﻟﻰ اﻟﻘﺮﻧﯿﺔ‪ ،‬ﻟﯿﺲ ﻏﺸﺎء ﻣﺜﻞ اﻟﻈﻔﺮة‬
‫‪Lacrimal‬‬
‫‪4-‬‬ ‫)‪Diffuse Bleb (SST‬‬ ‫ﺣﺎﺟﮫ ﺑﺰه ‪ ،‬ﻟﻮ ﺳﺄﻟﺖ اﻟﻤﺮﯾﺾ ﻋﻦ ﻋﻤﻠﯿﺔ ﻣﯿﺔ زرﻛﮫ‬
‫‪Apparatus‬‬
‫‪5-‬‬ ‫‪Subconjunctival‬‬ ‫‪ -‬ﯾﻤﯿﺰﻣﺎإذااﻟﺴﺒﺐ ﺧﺒﻄﺔ ﻟﻠﻌﯿﻦ أم ﻟﻠﺮأس‪...‬‬ ‫‪ -‬دم ﺳﺎﯾﺢ ﺗﺤﺖ اﻟﻤﻠﺘﺤﻤﺔ‬
‫‪Hge‬‬ ‫‪*Dacryocystitis:‬‬
‫‪6- Symblepharon‬‬ ‫اﻟﺠﻔﻦ ﻣﺎﺳﻚ ﻓﻰ اﻟﻌﯿﻦ‬ ‫‪-‬‬ ‫‪epiphora‬‬
‫‪7- Conjunctival‬‬ ‫ﺳﯿﺌﺔ ﻓﻰ اﻟﻌﯿﻦ‬ ‫‪-‬‬ ‫‪red swelling Lac. Sac‬‬
‫‪-‬‬ ‫‪+ve Regurge Test‬‬
‫‪Naevus‬‬
‫‪-‬‬ ‫‪ttt: DCR‬‬
‫‪8- Red Conjunctiva‬‬ ‫إرھﺎق ‪ ،‬إﻟﺘﮭﺎب ‪.... ،‬‬

‫‪9- Ciliary injection‬‬ ‫أوﻋﯿﺔ ﺣﻤﺮة و واﺿﺤﺔ ﻗﻮى ﺣﻮل اﻟـ ‪Keratitis, Iridocyclitis, Glaucoma ←Limbus‬‬

‫‪10- Conjunctival‬‬ ‫أوﻋﯿﺔ ﺣﻤﺮة و واﺿﺤﺔ ﻗﻮى ﺧﺎﺻﺔ ﻓﻰ اﻟـ ‪Conjunctivitis ←Fornices‬‬
‫‪injection‬‬

‫‪Cornea‬‬
‫اﻟﺤﺎﻟﺔ‬ ‫ﻛﯿﻒ ﺗﻌﺮﻓﮭﺎ‬

## ‫‪1-‬‬ ‫‪Pannus Siccus‬‬ ‫ھﻼل أﺑﯿﺾ ﯾﺤﯿﻂ اﻟﻘﺮﻧﯿﺔ ﻣﻦ ﻓﻮق‬

‫‪2-‬‬ ‫‪Arcus Senilis‬‬ ‫ﺣﻠﻘﺔ ﻋﺘﺎﻣﺔ ﺗﺤﯿﻂ اﻟﻘﺮﻧﯿﺔ )اﻟﻌﺠﻮز (‬

## ‫‪3-‬‬ ‫‪Nebula‬‬ ‫ﺳﺤﺎﺑﺔ ﻻﺗﺮاھﺎ إﻻ إذا اﻗﺘﺮﺑﺖ ﻣﻨﮭﺎ وﻧﻮرت ﻣﻦ اﻟﺠﺎﻧﺐ‬

‫‪4-‬‬ ‫‪Leucoma‬‬ ‫اﻟﺘﻰ ﺗﺠﺪ ﻣﻌﮭﺎ اﻟﻨﯿﻨﻰ ﻏﯿﺮ ﻣﻨﺘﻈﻢ‬ ‫‪ -‬إﻣﺎ ‪ LNA :‬اﻟﺘﻰ ھﻰ ﻋﺘﺎﻣﺔ ﻓﻘﻂ & ‪LA‬‬ ‫‪ -‬ﻋﺘﺎﻣﺔ ﺑﻀﺎء ﻗﻮﯾﺔ‬

‫‪5- Keratoconus‬‬ ‫ﻗﺮﻧﯿﺔ ﻗﻤﻌﯿﺔ ﻣﺨﺮوﻃﯿﺔ ﻣﺒﻈﺒﻈﺔ ﺷﻔﺎﻓﺔ ‪ :‬ﻟﻮ ﻧﻈﺮ ﻷﺳﻔﻞ ‪:‬‬
‫‪Angulation of LL on looking down ←Munson`s Sign‬‬

## ‫‪7- Ant. Staphyloma‬‬ ‫ﻗﺮﻧﯿﺔ ﻣﻌﺘﻤﺔ و ﻣﺒﻈﺒﻈﺔ ‪ +‬ﻣﺒﻄﻨﺔ ﺑـ ‪iris‬‬

Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺳﺒﺤﺎن اﷲ وﺑﺤﻤﺪه ﺳﺒﺤﺎن اﷲ اﻟﻌﻈﯿﻢ‬

Iris
‫اﻟﺤﺎﻟﺔ‬ ‫ﻛﯿﻒ ﺗﻌﺮﻓﮭﺎ‬
‫ ﻓﻮق‬-Part of iris is removed (near its root) Pupil
1- Peripheral iridectomy -Pupil remains round ‫اﻟﺤﺎﻟﺔ‬ ‫ﻛﯿﻒ ﺗﻌﺮﻓﮭﺎ‬

## 2- Sector iridectomy -Part of iris is removed

RRRCE =
(from:pupil to:ciliary border)
(Key-hole) 1- Normal Pupil regular, reactive, round,

## central, equal on both sides

-Small part of iris is removed: (Down+ In)
3- Visual iridectomy (near pupil,but not reach Ciliary border) - ‫ﯾﺘﺤﻚ ﻋﻠﯿﻚ وﯾﻌﻄﻰ اﻟﺤﺎج ﻗﻄﺮة ﺗﻮﺳﯿﻊ‬
- CRAO
‫ اﺳﺄﻟﮫ ھﻞ وﻟﺪ ﺑﮭﺎ‬- 2- Dilated fixed
4- Coloboma of iris - OA
- defect in iris - bilateral, down + in pupil
- Absolute glaucoma
- D-shaped pupil ‫ﺗﺠﻤﯿﻌﺔ ﻣﮭﻤﺔ ﺟﺪاااااااا ً ﻓﻰ‬
5- Iridodialysis - 3rd nerve palsy
- lost peripheral area of iris ‫اﻟﺸﻔﻮى‬
6- Iridodoneisis ‫( ﻗﺰﺣﯿﺔ ﺗﮭﺘﺰ‬tremulous iris) 3- An iso coria Un equal 2-pupils

7- Patches of iris atrophy ‫ أﺟﺰاء ﻣﯿﺘﮫ ﻣﺒﯿﻀﮫ ﻋﻠﻰ ﺳﻄﺢ اﻟﻘﺰﺣﯿﺔ‬- -Pupil isn`t
(central , round)
8- Anterior Synechia -iris + cornea: 4- Drawn up
( ‫ﻗﺰﺣﯿﺔ ﻣﺎﺳﻜﺔ ﻓﻰ ﻇﮭﺮ ﻗﺮﻧﯿﺔ ﺷﻔﺎﻓﺔ ) اﻟﻨﯿﻨﻰ ﻏﯿﺮ ﻣﻨﺘﻈﻢ‬ -Iris tissue is present all
Pupil
around pupil
9- Posterior Synechia -iris + lens ‫ ﻗﺰﺣﯿﺔ ﻣﺎﺳﻜﺔ ﻓﻰ اﻟﻌﺪﺳﺔ‬-

## Pupil -Ant, Post Synechia

Lens / Cataract
‫اﻟﺤﺎﻟﺔ‬ ‫ﻛﯿﻒ ﺗﻌﺮﻓﮭﺎ‬
- Developmental ‫ﻣﻮﻟﻮد ﺑﮭﺎ‬

- Traumatic
َ ‫اﺗﺨﺒﻂ‬
(Blunt Tr. & Penetrating Tr.)
‫ اﺳﺄﻟﮫ ﻋﻦ أﻣﺮاض ﯾﺸﺘﻜﻰ ﻣﻨﮭﺎ ﻣﺜﻞ اﻟﺴﻜﺮ واﻟﻀﻐﻂ‬-
- Complicated ‫ ﺳﻨﮫ‬٥٠ ‫ ﺳﻨﮫ ﺗﺤﺖ اﻟـ‬- َ ‫ ﻣﺎ اﺗﺨﺒﻂ‬-

## - Senile Cortical Incipient ‫ﻣﺜﻠﺜﺎت ﻓﻰ اﻻﻃﺮاف‬

‫ ﺳﻨﺔ‬٥٠ ‫ ﺣﺎج ﻛﺒﯿﺮ اﻟﺴﻦ ﻓﻮق اﻟـ‬- Immature Iris shadow + ‫اﻟﻌﺪﺳﺔ ﻓﯿﮭﺎﻋﺘﺎﻣﺔ‬

## Intumescent ‫ اﻟﻌﺪﺳﺔ ﻣﻨﻔﻮﺧﺔ و ﺑﺘﻠﻤﻊ‬- ‫ ﻋﺘﺎﻣﺔ ﻣﺜﻞ اﻟﺼﺪﻓﺔ أو ﻗﺸﺮ ﺳﻤﻚ‬-

Hyper mature:
‫ اﻟﻌﺪﺳﺔ ﻣﻨﻜﻤﺸﺔ و ﻣﻨﻘﻄﮫ أﺑﯿﺾ و أﺻﻔﺮ‬-
- Shrunken
‫ ﻟﺒﻦ و اﻟﻨﻮاة اﻟﺒﻨﯿﺔ ﻏﺎرﻗﺔ ﺗﺤﺖ‬-
- Morgagnian
- Senile Nuclear - brownish yellow opacity at Center of lens
‫ اﺳﺄل اﻟﻤﺮﯾﺾ ھﻞ ﻧﻈﺮه ﺑﯿﺘﺄﺛﺮ ﺑﺎﻟﻨﮭﺎر أﻛﺜﺮ‬-
- Aphakia ‫ ﺻﻮرة واﺣﺪة ﻓﻘﻂ ﻋﻠﻰ اﻟﻘﺮﻧﯿﺔ‬- ‫ ﻋﻤﻞ ﻋﻤﻠﯿﺔ ﻣﯿﺔ ﺑﯿﻀﮫ وﻣﺎ زرﻋﺶ‬:‫ اﺳﺄﻟﮫ‬-
‫ﻋﻤﻞ ﻋﻤﻠﯿﺔ ﻣﯿﺔ ﺑﯿﻀﮫ وزرع ﻋﺪﺳﺔ‬-
AC IOL
- Pseudophakia ‫ اﻟﻌﺪﺳﺔ ﻛﻠﮭﺎ اﻣﺎﻣﻚ‬-
‫ ﻋﻤﻞ ﻋﻤﻠﯿﺔ ﻣﯿﺔ ﺑﯿﻀﮫ وزرع ﻋﺪﺳﺔ‬-
PC IOL
‫ ﻋﯿﻨﮫ ﺑﺘﺴﺮج وﺑﺘﺒﺮق‬:‫ ﻣﺢ ﺣﺮﻛﺔ اﻟﻨﻮر‬-

## - After Cataract ‫ ﻋﻤﻞ ﻋﻤﻠﯿﺔ ﻣﯿﺔ ﺑﯿﻀﮫ وردت ﻋﻠﯿﮫ‬-

Pupil: ‫ ﻋﺘﺎﻣﺔ ﻓﻰ‬-