Clinical Examination Of Ocular Surface disorders.As Physicians,the code to perfect diagnosis and treatment depends on a bedrock of of a good HISTORY.
⚠️Remember:it's history,history,and history from beginning to the end to enable an accurate diagnosis.
An examination of the ocular surface needs to be systematic.A stepwise approach helps to ensure that important signs and symptoms are not missed.
Vision:start by assessing the the uncorrected visual acuity,pinhole and best corrected visual acuity.
Eyelids:examine the lid position and closure and check for entrepion(when eyelid turns in on itself),Trichiasis(lashes touching the eye) and lagophthalmos(a gap between between the upper and lower lid when the eyes are closed). Examine the lid margin and meibomian gland opening for abnormal positions,inflammations and plugging with secretions.Try to express the meibomian glands,using gentle pressure.
Tears:Assess the quality of the tear film by looking for discharges,debris and the tear meniscus height(to give an idea of quantity ).
Check the tear break-up time by instilling a drop of fluorescein and timing how long it takes for the tear film to disperse.A tear break up time of less than 10 seconds is abnormal.
Finally,perform the schirmer Test by placing a testing strip in the inferior conjunctival fornix and asking the patient to close their eyes for 5 minutes.A normal results is >15 mm.
Less than this suggests insufficient tear production,to varying degrees :mild is 9-14mm,moderate 4-8mm and severe is :<4 mm
Bulger conjunctiva and Sclera :Assess inflammation,scaring,haemorrhage,and abnormal swellings such as pinguecula,pterygium,or possible malignancies.
Tarsal conjunctiva :Evert the upper and lower lies.look for scarring,foreign body defects,inflammatory membranes,papillae and follicles.
Corneal Epithelium: Using a torch,look for foreign bodies,infiltrates,oedema,and deposits.is the light reelected off the eye's surface shiny(healthy),or rough and/or dull?.Also test for corneal sensation with herpes simplex or herpes Foster.
Corneal Stroma :look for stromal opacities.assess the size,location,pattern and depth.opacities may be scars or active inflamatory infiltrates.Look out for blood vessels :inactive have a clear,grey outline without blood.
Corneal Epithelium:Look for any guttata,Descemets folds,and the presence and any type of any deposits (blood,keratic precipitates,or pigments)
Problems affecting the ocular surface are broadly divided into:INFECTIOUS and NON INFECTIOUS conditions.
They present with a limited range of symptoms.the pattern of symptoms help differentiate between conditions.
For example: A person mainly complains of itching then allergic conjunctivitis needs to be considered as a possible cause.majority of these conditions can overlap,therefore careful examination is critical to reaching an accurate diagnosis