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Yeni anggraini I11107014





Distance between upper and lower lid margins
Normal upper lid margin rests about 2 mm below upper limbus Normal lower lid margin rests 1 mm above lower limbus

Amount of unilateral ptosis is determined by comparison

 A ptotic lid will cover more cornea and may partially or totally obscure the pupil. with the sclera visible  Graves’ orbitopathy (thyroid eye disease) – mild proptosis. right upper and bilateral lower lid retraction . If asymmetrical.  A retracted lid will cover little or no cornea.OSBSERVE THE LIDS Observe the upper eyelids for symmetry.  Observe lid position relative to the pupil and cornea.decide which lid is ptotic or whether the other lid is retracted.

• Observe the eyelashes—any missing? Are they growing in the correct direction or in-growing (trichiasis)? When appropriate.g. evert the ectropion . e. oedema. erythema. Note any lid lesions present. Look for evidence of inflammation.     Observe the lower eyelid position for entropion (lid turning inwards) or ectropion (lid everted outwards).

    Simple eversion The patient is asked to look down.EVERSION OF THE UPPER EYELID. Eversion should be performed with a quick levering motion while applying slight traction. This relaxes the levator palpebrae superioris and orbicularis oculi muscles. The palpebral conjunctiva can then be inspected and . The patient should repeatedly be told to relax and to avoid tightly shutting the opposite eye. The examiner grasps the eyelashes of the upper eyelid between the thumb and forefinger and everts the eyelid against a glass rod or swab used as a fulcrum.


 The patient looks up while the examiner pulls the eyelid downward close to the anterior margin.  This exposes the conjunctiva and the posterior surface of  .Eversion of the lower eyelid.

thickening. the palpebral conjunctiva can only be examined by everting the upper or lower eyelid.  The examiner should be alert to any reddening.  The bulbar conjunctiva is directly visible between the eyelids. shiny. secretion.  The normal conjunctiva is smooth.  Assesment of superior tarsal conjungtiva . and moist.EXAMINATION OF THE CONJUNCTIVA The conjunctiva is examined by direct inspection.

Appearance/texture of the conjunctiva:  —Are there tarsal conjunctival follicles or papillae? (These are pinkish or fine red velvety lumps.)  —Does the patient have chemosis (conjunctiva has an oedematous jelly-like appearance)?  Gross conjunctival chemosis and haemorrhage .


2. 7. lower left. straight ahead. lower right  This allows the examiner to diagnose strabismus. right. up. down. left.OCCULAR MOTILITY the examiner asks the patient to look in each of the nine diagnostic positions of gaze: 1.  . and 9. 4. and gaze paresis. 3. upper right. 6. upper left. paralysis of ocular muscles. 8. 5.


The motion impairment of the eye resulting from paralysis of an ocular muscle will be most evident in these positions.  Only one of the rectus muscles is involved in each of the left and right positions of gaze (lateral ormedial rectus muscle).  .  All other directions of gaze involve several muscles.



HIRSCHBERG TEST  Is an objective eye ball position assesment Patient look at light from distance 60 cm Deviation of eye : 1 m=7*  BAYANGAN JATUH TEPAT DITENGAH PUPIL    ET : outside shadow XT : inside shadow .

• Rough measure of deviation TEST HIRSCHBERG Note location of corneal light reflex • 1 mm = 7 or 15 • Reflex at border of pupil = 15 Reflex at limbus = 45 .




HETEROTROPIA GRADE ORTO tengah pupil 15 * ET tepi pupil 30* ET tepi limbus 45 *ET luar limbus .

 The examiner holds a point light source beneath his or her own eyes and observes the light reflections in the patient’s corneas in the near field (40 cm) and at a distance (5m).  The reflections are normally in the center of each pupil.  .BINOCULAR ALIGNMENT Binocular alignment is evaluated with a cover test.  Then the examiner covers one eye with a hand or an occluder and tests whether the uncovered eye makes a compensatorymovement. If the corneal reflection is not in the center of the pupil in one eye. then a tropia is present in that eye.

the baby will not tolerate the good eye being covered. However.Compensatory movement of the eye indicates the presence of tropia.  The cover test is then repeated with the other eye.  . If tropia is present in a newborn with extremely poor vision. there will also be a lack of compensatory movement if the eye is blind.

THE COVER TESTS        1. watch the other uncovered eye to see if it moves to take up fixation Remove the occluder and see if the original eye retakes up fixation. As you cover the eye. If it does. it is the preferred fixating eye and the other eye has a squint (non-alternating heterotropia) Do this for near and then distance vision . The cover–uncover test – to detect the presence of a squint: Observe if one eye is preferred for fixation Ask the patient to look at the fixation target – if in a child this can be a light or toy Occlude (for a few seconds) the eye that appears to be fixing.


        2. The alternate cover test – to detect a latent squint or phoria in a patient with straight eyes on cover test: Ask the patient to fixate on an object Cover one eye then rapidly move cover to the other eye Repeat rapidly several times Observe the movement of the covered eye as it becomes uncovered If it moves inwards to take up fixation the patient has an ‘exophoria’ Do test for near and then distance Also can be used with a prism bar to measure the maximum size of a squint .

When the left fixing eye is covered with an opaque occluder. the right eye moves inwards to take up fixation of the target. The squint is divergent (exotropia) .

the uncovered eye will not move to pick up fixation. the eye under the cover will move to re-establish fusion when the cover is removed. when a phoria is present.    A phoria is a latent deviation that can only be observed when binocular fusion is disrupted. The corneal light reflex will be symmetrical. When the cover test is performed. Phorias usually cause no problems and generally do not have to be further evaluated. the eye had been out (exophoria). . If the eye under the cover moves in when uncovered. However.

The red glass and Maddox Rod may be used to measure phorias or tropias or to determine if there is suppression in one eye. This technique elicits the largest deviation. neither can distinguish between a phoria and a tropia.  The occluder is moved back and forth across the bridge of the nose to alternately cover each eye without allowing fusion.Once a phoria or a tropia has been detected. since both instruments disrupt fusion.  . the cross-cover (or alternate cover) test may be used for measurement. However.