About your upcoming exam

• 50 questions • Multiple choice, four possible answers • All questions taken directly from lecture
– Lecture notes are available in the optometrie section in the library and online

• Similar in style to the last exam • No embryology • No slides

Lecture notes online
• For those who don’t have it, the URL is: • http://virtmed.fg.hvu.nl/domeinen/opto metrie/optometrie.html • The password is redeye

About your upcoming exam COSM3
• Questions per topic covered:
– Methods (direct and indirect examination of the fundus, tonometry, gonioscopy): 5 – Fundus Landmarks: 2 – Congenital variations: 8-9 – Optic Neuropathy: 13 – Fundus Spots: 21-22 – Total: 50

About your upcoming exam COSMB • Questions per topic covered: – DPAs: 15-16 – Methods (direct and indirect examination of the fundus. gonioscopy): 5 – Fundus Landmarks: 2 – Normal fundus: 7-8 – Congenital variations: 8 – Optic Neuropathy: 12 – Total: 50 . tonometry.

Tonometry .

Tonometry • One abbreviation that will be used throughout your career is IOP. which stands for intraocular pressure • Get used to it .

Tonometry • Measures tension in eye – The combined resistance of het oog (IOP) and the tear film • The main reason we measure this is because high pressure is a key indicator of glaucoma – Pressure is elevated in most types of glaucoma .

Tonometry • Pressure can also be high in cases of ocular inflammation – Uveitis • Perforating injuries to the globe may result in an abnormally low pressure – This is called hypotony .

Tonometry • Measured in mm Hg • There are three ways to measure IOP – Manometry – Applanation – Indentation .

Tonometry • Manometry – The most accurate method of determining IOP – A needle connected to a column of mercury is inserted into the eye – Not generally performed in clinical practice .

and the worldwide standard • Also using this theory is the Maklolov unit . pressure is directly related to the other variable – The Goldmann tonometer is the one we use.Tonometry • Applanation – Based on the Imbert-Fick formula – IOP = force/area – This is the same formula used in physics – If one measure is kept constant.

Tonometry
• The Goldmann tonometer has a constant area
– The force required to flatten the cornea is directly related to the IOP

• The Maklokov tonometer applies a constant force
– The area flattened is directly related to the IOP

Tonometry
• Indentation
– A constant force applied to the cornea – The cornea is pushed posteriorly – The IOP is related to the distance the cornea is pushed – Influenced by corneal rigidity
• Tends to be lower in high myopes, who have larger eyes and therefore slightly softer corneas

– Aqueous humor is forced from the eye
• Subsequent readings will be lower

Tonometry
• Normal IOP
– The average IOP is 16 mm Hg – Normal IOP is anywhere from 6 to 21 mm Hg – An eye with an IOP under 6 is considered hypotonous
• Look for a wound leak (do the Seidel test)

but for them this is normal • You should make sure of your diagnosis of ocular hypertension with your anamnese and other tests .Tonometry • Normal IOP – An eye with an IOP over 21 is referred to as hypertensive • Most people with ocular hypertension do not develop glaucoma • What this means is that some people have pressure which is higher than most others.

or forceful blinking. so you have to force them open • By doing this. giving a false high reading • Blepharospasm. you can inadvertently press on the globe. can do the same thing .Tonometry • Physical factors affecting IOP – Pressure on Globe • Holding lids--some people just won’t keep their eyes open no matter what you say.

IOP is slightly lowered due to decreased aqueous production – In the later stages. IOP increases as a result of cells and flare. clogging the trabecular meshwork .Tonometry • Physical factors affecting IOP – Trauma/Inflammation • Damage to the trabecular meshwork will prevent the proper drainage of aqueous from the eye – This happens in angle recession glaucoma • Uveitis – In the beginning of the condition.

alpha agonists.Tonometry • Physical factors affecting IOP – Medications – Steroids • Use of these over a long period of time causes in increase in IOP in about 1/3 of all people – Blood pressure medication • Beta blockers. and carbonic anhydrase inhibitors can lower IOP – Marijuana/alcohol • The effect is gone when it leaves the body .

Tonometry • Physiological factors affecting IOP – Diurnal variation • IOP is highest at around 10AM. get a morning reading • If still unsure. but may be twice that in glaucoma • If you suspect glaucoma in a patient with high pressure. you can do a diurnal curve • Start in the morgen. and lowest in the late avond • Normal variation is 4mm Hg per day. and read IOP every 1-2 uur .

there will be low IOP from decreased aqueous production • Since this occurs throughout the eye.Tonometry • Physiological factors affecting IOP – Vascular integrity • In cases of hypoxia. there may be nerve damage despite low IOP • Patient position for measurement • IOP is 2-3 mm higher lying down • This is not a problem with current techniques .

Tonometry • Techniques – Finger tensions (digital IOP) – Goldmann – Perkins – Non-contact – Pulsair – Tonopen – Pneumotonometer – Maklakow Glaucotest .

or hard .Tonometry • Finger tensions (digital IOP) – Not accurate – Should only be done when all other methods are not possible – Lightly push on the closed eye – Compare each eye to the other – Rate whether soft. normal.

including Perkins .Tonometry • Goldmann applanation tonometry – Is the “gold standard” because of its accuracy and repeatability – The only method used to diagnose and treat glaucoma – Used with the spleetlamp – There is also a hand-held version made by many companies.

which is called a mire • When the mires are aligned properly.06mm of the cornea is applanated (flattened) by the tip • The prisms split the image horizontally to permit a proper measurement • Each half of the image contains a semi-circle. you have determined the IOP .Tonometry • Goldmann applanation tonometry – Uses a tip which has prisms inside • The tip is 7mm in diameter. but only 3.

Tonometry • This is what the mires look like when the unit is properly aligned and the IOP reading is correct .

Tonometry • Procedure for Goldmann tonometry – Disinfect tonometer tip • Soak in 3% peroxide solution (contact lens solutions work well) for tien minutes and then rinse with saline solution – Place tip in holder – Align 180º mark of tip with horizontal line • If the patient has more than drie diopters of corneal astigmatism. place the minus cylinder axis along the red line of the tonometer .

Tonometry • Procedure for Goldmann tonometry – Place a drop of anesthetic in het oog – Instill fluorescein – Switch to diffuse illumination of maximum intensity with the cobalt blauw filter – Observe cornea for staining – Start with the right oog – Pull spleetlamp back – Place illumination system at 60º temporally .

Tonometry
• Procedure for Goldmann tonometry
– Set measuring drum at 10
• Note: the drum has numbers 0-8 on it. These stand for 0 through 80. There are four lines between each number. These correspond to twee mm Hg each. • The line by the number 1 is 10 mm Hg. The line after that is 12mm Hg. If the reading is between the first and second lines after the number 1, this is a reading of 13 mm Hg.

Tonometry
• Procedure for Goldmann tonometry
– Place tip in position, directly facing the patient – Have the patient look straight ahead – Bring tip toward het oog, looking from outside the spleetlamp – When the limbus has a blauw glow, look through the eyepieces – Move spleetlamp forward until you see the mires

Tonometry
• Procedure for Goldmann tonometry
– Adjust the mires until they are centered – Turn the drum until the mires are properly aligned – Remove tip – Check for staining again

So in the picture on the right. you would lower the spleetlamp.Tonometry • To properly align the mires vertically. In the picture on the right. move the spleetlamp in the direction of the mires. you would have to move the instrument to the right as well as up. In the picture on the left. you would have to raise the instrument. and this would align the mires. . To align the mires horizontally. move the spleetlamp in the direction of the larger mire.

. the inside edges of the mires should touch.Tonometry • To have a proper reading. The picture on the left requires you to increase the reading on the power drum. The picture on the right requires a decrease in the reading. The picture in the center shows a tonometer where the power is correct.

the fact that you told the patient not to rub their eyes. write them all down and average them. the drop used.Tonometry • To properly record. the IOP reading. the time it was done. and if the lids were held. The method we use here is below. If multiple readings were taken. 15 16 1 Oxybuprocaine 16 30 lids ✗ held . you must document the test used.

Tonometry • If there is too much fluorescein. the mires will be too thin and you will get a false low reading . the mires will be too thick and you will get a false high reading • If there is not enough fluorescein. as in the picture on the left. as in the picture on the right.

as in the picture on the right. the mires will go in and out of view . as in the picture on the left. you will have distorted mires which will not move when you change the reading drum • If you are not pushing hard enough.Tonometry • If you are pushing too hard on the eye.

you must move the spleetlamp and the power drum with your other hand – Scarred corneas give distorted mires .Tonometry • Things to remember – Alignment for excessive corneal cylinder – If a patient has an ocular pulse (also called a hippus) then the reading will fluctuate • Set the reading so that the center of this movement will be where proper alignment is – If you must hold the lids.

Tonometry • The hand-held tonometer works the same way as the Goldmann tonometer • The power wheel is controlled by your thumb • You should also record the patient’s position .

Tonometry • Non-contact tonometry (NCT) – Works by applanation (by air) – A puff of air flattens a fixed area of cornea – The air stops when the cornea is flattened enough to allow a light to be reflected to a receiver – The amount of air needed is related to the IOP. and the machine displays the nummer – Must average drie readings per oog – OK for screening purposes .

Tonometry Non-Contact Tonometer (NCT) Air pulse Light source air pulse Monitoring mirror system .

Tonometry • Non-contact tonometry procedure – Disinfect chin & headrest – Demonstrate puff – Switch instrument to regular mode – Align patient comfortably – Patient closes eyes – Set and test safety lock – Pull instrument slightly back – Have patient open their eyes .

Tonometry • Non-contact tonometry procedure – Direct fixation – Align targets – Instrument may shoot automatically or manually – Take drie readings and average – Documentation is the same as with the Goldmann .

Tonometry • Keeler Pulsair non-contact tonometer – We have one of these in the preclinic – Hand held – Portable – Can be used in any position – Requires a steady hand – Machine averages vier readings .

digital. well tolerated – Excellent back-up for Goldmann . portable.Tonometry • Tonopen – Uses a combination of applanation & indentation techniques – Hand-held. quick.

Tonometry • Tonopen procedure – Calibrate instrument – Place sterile disposable cover over tip – Anesthetize eyes – Direct fixation – Press reading button listen for beep – Hold instrument perpendicular to cornea .

then you should repeat the procedure – It tends to overestimate low IOP and underestimate high IOP .Tonometry • Tonopen procedure – Gently tap the cornea 3-5 times – The instrument makes a sound every time it gets a reading – If it is not reliable.

so you have a clue if some old-timer starts talking about them • Obviously. Pneumotonometer.Tonometry • I’m still trying to figure out why the Schiotz. • None of these have been used in clinical practice for years • Read them over once. they will not be on the exam . and Heine-Maklakow instruments are in the module.

Gonioscopy .

Gonioscopy • Technique used to view the anterior chamber angle • It is impossible to directly view the angle with the spleetlamp alone • We need special lenses/prisms .

Gonioscopy .

neovascularization – Pigment dispersion syndrome – Pseudoexfoliation. neoplasm. exfoliation – Glaucoma has been diagnosed or is suspected .Gonioscopy • Indications: – Grade 2 or less on Van Herrick technique – Suspicion of abnormality in angle • trauma. maldevelopment.

Gonioscopy • Contraindications: – Traumatic hyphema – Corneal abrasion – Laceration or perforation – Post-surgery .

virtual image – The most common is the Koeppe lens.Gonioscopy • Direct gonioscopy – High plus lens. and magnifier – You can look directly into the angle – You can view the angle 360º around – It provides an erect. light source. which provides 24X magnification – Patient must be lying down – This is rarely used .

Gonioscopy Koeppe lens .

virtual images – Goldmann. Sussman.Gonioscopy • Indirect gonioscopy – Mirrors and prisms are used in combination with the spleetlamp – The mirrors and prisms do not magnify – The mirror/prism should be 180º away from the angle you want to observe – Inverted. Posner. Zeiss make lenses for this purpose – Scleral and corneal lenses are used .

therefore they rest on the sclera – Require a solution to keep a tight seal • It should be relatively thick .Gonioscopy • Scleral lenses – There are many types available • The most common is the Goldmann 3-mirror – They are larger in size than the cornea.

Gonioscopy • Corneal lenses – They have a smaller diameter than the cornea – They rest on the tear film – They do not require a solution to stick to het oog – There is limited lens manipulation – These are less stable than scleral lenses – Some have a handle for better control .

they are: – Iris root (IR) – Ciliary body (CB) – Scleral spur (SS) – Trabecular meshwork (TM) – Schwalbe’s line (SL) .Gonioscopy • There are vijf major structures that need to be evaluated in every angle • From posterior to anterior.

Gonioscopy The easiest way to remember the structures is to remember this statement. in which the words all start with the same letters as the anatomical structures • • • • Iris root (IR) Ciliary body (CB) Scleral spur (SS) Trabecular meshwork (TM) • Schwalbe’s line (SL) • • • • • I Can’t See This S%@# .

Gonioscopy .

Gonioscopy .

Gonioscopy • There are other things that we need to look for as well – Iris processes – Iris/angle neovascularization – Peripheral anterior synechiae (PAS) – Pigment .

it is called Sampaolesi’s line – There is a specific method used to see this structure .Gonioscopy • Schwalbe’s line – The termination of Descemet’s membrane • Where the cornea ends – Color varies from clear to light brown – If anterior chamber pigment is deposited here.

Gonioscopy • Schwalbe’s line – Use an optic section rather than a parallelpiped to see where it is – The light will shine on both the cornea and angle – Where they meet is Schwalbe’s Line .

Gonioscopy .

Gonioscopy .

Gonioscopy • Trabecular meshwork – Is composed of fenestrated sheets of epithelium – Its function is to remove aqueous from het oog – It can be subdivided into anterior and posterior .

you can observe Schlemm’s canal. it will be red from blood .Gonioscopy • Trabecular meshwork – The anterior portion is less pigmented – The posterior part does more of the work • Therefore more pigment will accumulate hier – The actual color depends on the pigmentation of the patient and the amount of free pigment available – If you push hard on the lens.

Gonioscopy .

Gonioscopy Blood in Schlemm’s canal .

Gonioscopy • Scleral Spur – Ring of collagen and elastic tissue – Is the end of the trabecular meshwork – The longitudinal muscles of the ciliary body insert here – Appears as a white line – May not be easily found in light eyes. as there is no pigment to contrast with .

Gonioscopy .

Gonioscopy • Ciliary body – It has many functions • Aqueous production • Accommodation • Point of attachment for iris – Most of it lies behind the iris – We can only see the ciliary body band – The color varies depending on the patient’s overall pigmentation .

Gonioscopy • Iris root – This is the end of the iris – You must observe how it attaches to the ciliary body – In cases of trauma: • The iris may be torn. which is known as an angle recession • 9% of all patients with angle recessions develop glaucoma as a result . which is called iridodialysis • The ciliary body may be torn.

Gonioscopy .

Gonioscopy • Iris processes – A normal finding – Are fine strands of iris that attach to the trabecular meshwork – You must distinguish from these from anterior synechiae and neovascularization .

Gonioscopy Iris processes .

Gonioscopy Iris Processes .

Gonioscopy • Iris/Angle Neovascularization – Also known as rubeosis irides – New bloedvat growth • These vessels are fragile and leaky – Fibrin leaks out of the bloedvat and attaches itself to the angle structures. stopping the flow of aqueous – This happens in response to ischemia .

iris processes are thin and lacy – They usually attach to the trabecular meshwork or Schwalbe’s line. but may attach to the cornea or ciliary body as well – These can close the angle completely .Gonioscopy • Peripheral anterior synechiae (PAS) – Are areas of the iris that have become attached to angle structures – These are irregular. and often obscure your view of the angle • In comparison. thick.

inflammation. and after laser procedures • You can also see tumors in the angle . trauma.Gonioscopy • Peripheral anterior synechiae (PAS) – Can be caused by angle closure. neovascularization.

Gonioscopy Peripheral anterior synechiae .

Gonioscopy .

Gonioscopy .

Gonioscopy Indirect Corneal Lens .

Gonioscopy Indirect corneal lens procedure – Educate and anesthetize the patient – Disinfect and rinse lens – Patient is placed behind the spleetlamp – Observation and illumination systems at 0º – 2-3 mm parallelpiped – Pull spleetlamp all the way back – The patient should look straight ahead – Place lens on het oog .

and 12 o’clock – Stabilize your hand on the head rest or on the patient’s cheek – Gently press against corneal surface – Look in a different mirror to observe a different angle – Pull the lens away to remove it • It comes off very easily. which should be at 3.Gonioscopy • Indirect corneal lens procedure – The lens has four mirrors. 6. 9. unlike the scleral lens .

and horizontal for the nasal and temporal angles . use an optic section • The beam should be vertical for the superior and inferior angles.Gonioscopy • Indirect corneal lens procedure – You should use the parallelpiped to observe the entire angle • The beam should be horizontal for the superior and inferior angles and vertical for the nasal and temporal angles – To look for Schwalbe’s line.

have the patient look slightly toward the mirror .Gonioscopy • Indirect corneal lens procedure – More difficult to use than the scleral lens – The examiner must be very steady – You must maintain good contact with the tear film without wrinkling Descemet’s or causing blood to back up into Schlemm’s canal – If the patient has a bowed iris.

Gonioscopy Wrinkling of Descemet’s membrane .

then the closure is from synechiae – This is not easy to treat .Gonioscopy • Indentation gonioscopy – Only done with corneal lenses – Used to determine if a closed angle is that way because of synechiae or apposition • You will see structures if the closure is a result of apposition – This can be treated with a peripheral iridectomy • If none are seen.

Gonioscopy Indentation gonioscopy This angle is closed due to apposition .

some contradict others – The most common and clinically useful method is to: Record the most posterior structure seen Grade pigmenting of the trabecular meshwork Indicate any abnormalities – Evaluate in all vier quadrants and record on an “X” .Gonioscopy • Angle classification – There are many methods.

Gonioscopy • Angle classification – Read over the Schaffer and Scheie systems – They are actually graded opposite of the van Herrick technique and can create confusion for examiners – This is why the previously described method is widely used – However. a new system has emerged and it is what we use in our clinic .

Gonioscopy Spaeth angle classification We must determine vier things – The site of iris insertion – The iris approach – The angle of insertion – The amount of pigment – This system allows for recording of iris processes and results of indentation gonioscopy .

trabecular meshwork is not visible – sCleral spur –Deep angle.Gonioscopy • Spaeth angle classification – Site of insertion –Anterior to Schwalbe’s line –Behind Schwalbe’s line. with visible ciliary body –Extremely deep .

Gonioscopy .

Gonioscopy • Spaeth angle classification – Iris approach –queer--concave iris –regular configuration –steeply convex (bowed) iris .

Gonioscopy .

Gonioscopy Spaeth angle classification Insertion angle (in degrees) .

Gonioscopy Recording OD E 40 r 0 pigment OS B 10 s 1 pigment A 10 s 4+ synechiae E 40 q iris neo recession C 25 r 4+ pigment Normal Abnormal .

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