Inspect the palpebral conjunctiva by everting the lids.
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This guide provides a step-by-step approach to assessing the anterior segment of the eyes and includes a video demonstration. Download the anterior segment eye examination PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in some of our other relevant OSCE guides including fundoscopy, examination of the eyes and vision, blind spot assessment and colour vision assessment. Gather equipmentGather the appropriate equipment:
IntroductionWash your hands and don PPE if appropriate. Introduce yourself to the patient including your name and role. Confirm the patient’s name and date of birth. Briefly explain what the examination will involve using patient-friendly language. Gain consent to proceed with the examination. Position the patient sitting on a chair. Ask if the patient has any pain before proceeding. General inspectionAsk the patient to look straight ahead and inspect both of the eyes assessing the following:
Note any abnormalities such as:
Pupillary assessmentThe 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 sizeNormal 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 symmetryNote any asymmetry in pupil size (anisocoria). This may be longstanding and physiological or be due to acquired pathology. If the difference in pupil size becomes greater in bright light such as when facing a window in daylight, this would suggest that the larger pupil is the pathological one. This is because the normal pupil will constrict in brighter light accentuating the difference in size. If the difference is more pronounced in dim lighting, this would imply the smaller pupil is abnormal as the 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 shapePupils 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 colourAsymmetry 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.
Pathology which may be noted during general inspectionExamples of pathology you may note during general inspection of the eye include:
White light assessmentOphthalmoscope settingsTo set up the ophthalmoscope for assessing the anterior surface of the eye:
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 light1. 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:
Assessment of anterior chamber depth7. Assess the depth of the anterior chamber (the space between the cornea and the iris):
Blue light assessment1. Add some fluorescein to the lower fornix either with a moistened strip or as a drop. 2. Switch to the blue light on your device. With an ophthalmoscope, this is typically done by rolling a filter wheel at the base of 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 fluoresce highlighting:
4. Record the location and size of any epithelial loss/disease.
Superior tarsal plate assessment1. 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 magnified look with your device.
Anterior segment pathologyExamples of clinical signs and pathology you may note on assessment of the anterior segment include:
To complete the examination…Repeat the above assessments on the other eye if appropriate and compare your clinical findings. Explain to the patient that the examination is now finished. Thank the patient for their time and explain your findings and management plan. Dispose of PPE appropriately and wash your hands. Suggest further assessment and investigationsAll of the following further assessments and investigations are dependent on the patient’s presenting complaint: What should you check for when viewing the conjunctiva of the eyes?Check if you have conjunctivitis
red. burn or feel gritty. produce pus that sticks to lashes.
What is palpebral conjunctiva?The palpebral conjunctiva lines the eyelids. The bulbar conjunctiva is found on the eyeball over the anterior sclera. Tenon's capsule binds it to the underlying sclera. The potential space between Tenon's capsule and the sclera is frequently used for local anesthesia.
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