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    Default Anterior segment manual for BEGINNERS in Ophthalmology

    By Prof Dr.Gehad Elnahri

    This short anterior segment manual is meant only for BEGINNERS in Ophthalmology


    A "Meaningful Routine"; a short manual for BEGINNERS

    Why does ocular examination seem so challenging to the beginner trainee?
    1)because he finds himself alone with this wonderful machine; the slit lamp
    2)because he lacks the "meaningful routine"; what am i looking at and why?

    Anterior segment manual BEGINNERS Ophthalmology attachment.php?attachmentid=3227&d=1500061999

    The first advises i give to my trainees are
    1)Forget everything but
    -how to test vision properly,
    -use the slit lamp on normal eyes and
    -develop a meaningful routine of examination

    2)memorize the shortest classification of "defined" eye diseases; details will come faster than you imagine
    Let me give some examples:
    Eyelid diseases include
    1)Cold Swellings
    2)Hot swellings (Inflammations)
    3)lid margin problems
    4)Malpositions
    5)Masses

    This is a frequency arrangement
    Now cold swellings are passive lid edema or hematoma
    Hot swellings are localized (styes and chalazia) or diffuse
    Malpositions are ptosis, entropion and ectropion and lagophthalmos
    Masses are benign and malignant

    No details except what are these diseases; not bothered by lists of causes, complications or extensive treatment details
    His examination routine should be Spotting and properly Categorizing these changes
    1)lid positions; i should know and look for the proper positions of upper and lower eyelids and their swellings, including closed eyelids
    2)the lid margin
    3)any change in lid color
    4)any lid masses
    Now what is the normal position of the upper eyelid, lower eyelid, the lid margin and the globe, the visibility of the punctum, the horizontal lid laxity? This should be my normal lid routine

    The Conjunctiva
    The diseases are
    1)Inflammations
    2)degenerations
    3)masses

    Inflammations
    are most revealed in the upper fornix (warmer and more secluded) so we have to learn to evert the upper lid
    Degenerations are pinguecula that do not cross the limbus, pterygium that crosses the limbus; symblepharon; adhesions seen in lower fornix
    Masses are generally limbal.

    The Meaningful Routine for the lid and conjunctiva YOU HAVE to DO on NORMALS
    1)upper eyelid position; covers 2 mm cornea; more=ptosis, less=retraction or proptosis
    2)lower lid position; touches the limbus; more=lower lid ptosis, less=as upper----exophthalmometry
    3)lid margins; thickness, lashes, meibomian orifices, sharpness of posterior border, telangiectasia, small masses, Inspect Puncti, Marginal tear strip
    4)closed lid; test Bell's phenomenon
    5)lid laxity in elderly; horizontal and vertical; snap back test
    6)inspect lower fornix; mucous, discharge, fibrosis, shortening, follicles, symblepharon
    7)inspect bulbar conjunctiva and limbal area
    8)Evert upper eyelid

    Corneal diseases
    1)inflammations
    2)edema
    3)degenerations
    4)dystrophies
    Inflammations are ulcerative (stain with fluorescein) or non ulcerative (no stain but limbus is hyperemic and red)
    Ulcers are central (or paracentral) and peripheral
    Degenerations are unilateral opacities or bilateral associated with age or vessels (post inflammatory); may be raised or depressed
    Dystrophies are bilateral symmetrical central young hereditary with no vessels or inflammation

    Corneal Routine
    1)diffuse illumination
    2)focal illumination (slit)
    3)retroillumination (if pupil dilated)
    4)specular reflection
    5)stain with fluorescein
    6)test sensation

    AC Routine
    1)DARK ROOM, before fluorescein
    2)Short slit (1x1 or 2x2)
    3)oblique illumination (45 deg)
    4)against the lens not iris
    Once you come across a case of anterior uveitis, you have to make the most out of it, darken the room and You HAVE to see flare, cells and kps. If you See them twice you will pick them up more easily

    Iris Routine
    1)color and symmetry of colors
    2)stroma and pattern; any nevi or hypopigmented spots
    3)any synechia to lens
    4)pupil margin and reaction to light
    5)transilluminate through a dilated pupil

    Lens Routine
    Do not try to examine the lens through a normal pupil, this is fruitless
    1)darken room, dilate
    2)look at many normal lenses; try to recognize anterior capsule with its shagreen, define cortex from nucleus, reach the back of the lens and vitreous, try to identify the Y sutures
    3)spend sometime looking at the anterior hyaloid behind the lens in the normal; it is Very Useful

    Seniors tend to drown juniors in details thinking this will shorten the path; juniors tend to follow thinking they will learn faster
    This is Wrong; you will have more memorized knowledge FASTER but you will remain a POOR eye examiner
    Always Know What you are Doing and Why are you Doing it











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