11/13/24, 6\:54 PM Guide | Anterior segment eye examination

Anterior segment eye examination

Table of contents
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Gather equipment

Gather the appropriate equipment\:
Ophthalmoscope (traditional device or Arclight)
Fluorescein eye drops
Cotton bud (for everting the eyelid and manipulating the conjunctiva)
Local anaesthetic drops if available

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Position the patient sitting on a chair.
Ask if the patient has any pain before proceeding.

General inspection

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Ask the patient to look straight ahead and inspect both of the eyes assessing the following\:
Peri-orbital regions
Eyelids
Eyes (including pupils)
Note any abnormalities such as\:
Swelling
Redness
Discharge
Prominence of the eyes
Abnormal eyelid position\: ptosis can be a sign of Horner’s syndrome (often very subtle ptosis with miosis) and oculomotor
nerve palsy (can vary from partial to complete ptosis and usually with a 'down and out' eye position and an enlarged pupil)
Abnormal pupillary shape, size and/or asymmetry

Pupillary assessment

The pupil is the hole in the centre of the iris that allows light to enter the eye and reach the retina.
Inspect the patient's pupils for abnormalities.
Pupil size
Normal pupil size varies between individuals and depends on lighting conditions (i.e. smaller in bright light, larger in the dark).
Pupils can be smaller in infancy and larger in adolescence, then often smaller again in the elderly.
Pupil symmetry
Note any asymmetry in pupil size (anisocoria). This may be longstanding and physiological or be due to acquired pathology. If
the di
the larger pupil is the pathological one. This is because the normal pupil will constrict in brighter light accentuating the
di
larger pupil would then dilate while the pathologically small pupil remains the same size.
Examples of asymmetry include a larger pupil in oculomotor nerve palsy and a smaller one in Horner’s syndrome.
Pupil shape
Pupils should be round. Abnormal shapes can be congenital or due to pathology (e.g. posterior synechiae associated with
uveitis) or previous trauma and surgery.
Peaked pupils in the context of trauma are suggestive of globe rupture (the peaked appearance is caused by the iris plugging
the leak).
Pupil colour
Asymmetry in pupillary colour is most commonly due to congenital disease.
In rare cases, asymmetry of colour can suggest Horner's syndrome, with the paler washed-out iris being pathological.
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Inspect eyes at rest
Pathology which may be noted during general inspection
Examples of pathology you may note during general inspection of the eye include\:
Periorbital erythema and swelling\: a feature of preseptal cellulitis (anterior to the orbital septum) or orbital cellulitis
(posterior to the orbital septum)
Eyelids\: lumps (benign or malignant), oedema, ptosis and entropion/ectropion
Eyelashes\: loss of eyelashes (can be associated with malignant lesions), trichiasis (eye lashes rubbing on the cornea)
and blepharitis collarettes
Pupils\: abnormal size, shape, colour and symmetry (see above)
Conjunctival injection (redness)\: this can be di
infection, allergy, trauma and in
Cornea\: di
of the cornea with
Anterior chamber\: a
yellow in colour).
Discharge\: watery discharge is typically associated with allergic or viral conjunctivitis or reactive physiological
production (e.g. corneal abrasion/foreign body). Purulent discharge is more likely to be associated with bacterial
conjunctivitis. Very sticky, stringy discharge can suggest chlamydial conjunctivitis while blood staining can be seen
with gonococcus.

White light assessment

Ophthalmoscope settings

To set up the ophthalmoscope for assessing the anterior surface of the eye\:
Turn on the white light of the ophthalmoscope
Adjust the diopter dial to a high green number (e.g. +10 to +20). The ophthalmoscope focal plane is now very short (5 to 10
cms) and will magnify your view.
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When using the Arclight, click through until the white light comes on at the loupe end of the device (there is a range of
brightness settings - start with the most appropriate for your patient). Children typically only tolerate a dimmer light initially.
Increase the brightness if the patient allows.

Assessment using white light

1. Set up your device as described above.
2. Stand to the side of the patient and place your hand on the patient's forehead to prevent an accidental collision.
3. Carefully approach the right eye with your right eye, until the front of the eye comes into focus. On the ophthalmoscope, this
will vary depending on the power of the lens selected. If using the Arclight, the front of the eye will be in focus at 6cms.
4. Ask the patient to look outwards and then inwards. Note the various structures whilst looking for any abnormalities.
5. Ask the patient to look upwards whilst you gently hold their lower eyelid to assess the lower areas of the eye ball and lids.
6. Then ask the patient to look downwards whilst you gently hold their upper eyelid to assess the upper areas.
During the assessment, it can be useful to think about the structures of the anterior eye and possible clinical signs in the
following three groups\:
Eyelashes and lid margins (upper and lower)
Conjunctiva, sclera and lower fornix
Cornea, limbus and pupil
Approach the right eye until it comes into focus
Assessment of anterior chamber depth
7. Assess the depth of the anterior chamber (the space between the cornea and the iris)\:
Shine a light from the temporal side of the eye to assess the depth
A shadow on the nasal iris can suggest a shallow anterior chamber
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Assess the depth of the anterior chamber

Blue light assessment

1. Add some
2. Switch to the blue light on your device. With an ophthalmoscope, this is typically done by rolling a
the head. With the Arclight, click the button until it comes on after the white lights.
3. Inspect the surface of the eye with the blue light. The dye will
The tear
Areas of epithelial loss (e.g. corneal abrasion) and disease (e.g. corneal ulcer)
4. Record the location and size of any epithelial loss/disease.
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Inspect the surface of the eye using the blue light

Superior tarsal plate

1. Place a cotton bud on the skin of the upper eyelid.
2. Gently lift the eyelid upwards whilst simultaneously pressing downwards with the cotton bud.
3. Initially observe the superior tarsal plate for any abnormalities with your naked eye then take a magni
device.
Place a cotton bud on the upper eyelid
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Anterior segment pathology
Examples of clinical signs and pathology you may note on assessment of the anterior segment include\:
Foreign body\: may be visible on the surface of the eye or embedded within the cornea or sclera with a rust ring if
metallic. Associated clinical features include in
.
Remember to perform eyelid eversion\: foreign bodies may be hidden under the top or bottom lids or stuck to the tarsal
plate.
Hyphaema\: a layer of settled blood in the anterior chamber often due to blunt trauma.
Hypopyon\: a layer of settled ‘pus’ (white cells and debris) in the anterior chamber. Typically associated with severe
corneal ulcers or endophthalmitis, but can also be seen in bad anterior uveitis.
Corneal abrasion\: redness, pain, watering and photophobia are common clinical features. Epithelial defects can be
hard to see with the naked eye but will stain brightly and clearly when stained with
magni
Corneal ulcer\: typical clinical features include blurred vision, pain, watering, photophobia and a staining epithelial
defect with associated haziness (in
hypopyon may also be present. Corneal ulcers are common in contact lens wearers.
Limbal injection\: dilated blood vessels at the junction of the cornea and sclera (limbus). This
intraocular in
Uveitis\: limbal injection (typically unilateral), white deposits on the inside surface of the lower part of the cornea
(keratic precipitates), misshapen pupil (posterior synechiae), watery eye with blurred vision and photophobic pain are
common features.
Acute angle-closure glaucoma (AACG)\: pain in and around the eye as well as generalised headache with nausea and
vomiting. Reduced visual acuity with haloes around bright lights is characteristic. The cornea can become di
hazy with the pupil becoming mid-dilated and unreactive to light. Due to the high pressure, the a

Subconjunctival haemorrhage\: a painless type of red eye with a
de
Episcleritis\: sectoral area of super
anaesthesia) when pressed gently on the surface.
Scleritis\: deep red-purple localised conjunctival/scleral redness (unilateral). Will not move when touched with a
cotton bud. Minimal watering, but very sore, especially to touch (may wake the patient from sleep). Can be associated
with connective tissue diseases such as rheumatoid arthritis.
Dry eye\: reduced quality and volume of tear production. Most commonly age-related, but can also be secondary to
conditions such as blepharitis (obstruction of meibomian glands) and connective tissue diseases. Clinical features
include di
cornea with a reduced or absent tear meniscus can be seen. When due to blepharitis, in
crusting and matted eyelashes may be present.
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