Use of the slit-lamp for anterior segment examination of the eye - Case Study Example

Reflective Report: Use of the Slit-lamp for Anterior Segment Examination of the Eye Introduction In my clinical placement in the Ophthalmology, I hada chance to examine a patient who presented complaining of decrease in vision. For confidentiality and ethical reasons, the identity of this patient remains undisclosed. However, this 65-year-old gentleman presented to the clinic, and when I was instructed to do a slit-lamp examination, it felt that it was an opportunity to use academic learning in practice, and I was very excited. History This gentleman complained of progressive loss of vision and requirement of frequent changes in glasses over a period of last 1 year, more so over the last 6 months. He does not have any significant or leading family history, he wears glasses, he has no history of recent trauma to the eyes, and his medical history does not reveal any history of diabetes mellitus, hypertension, thyroid disease, rheumatoid arthritis, or malignancy. In order to arrive at a diagnosis, I obtained these systemic medical history and family ocular history, since these are important for assessing a patient's risk factors for ocular disease. Just as with other body systems, reliable historical information allows the clinician to more appropriately direct the physical examination (Quillen, 1999). History Pertaining to the Visual Loss I probed into his recent complaints in terms of the onset, duration, and associated symptoms, since knowledge about these can guide me to the correct diagnosis. I asked him about his prior good and equal vision in both eyes. Then I asked him whether the problem were on the both eyes, and how could he not note it for last 1 year. He said that he was going on with his frequent changes in glasses, which he thought was natural at his age. While watching television, he suddenly discovered that his vision in the right eye was a lot better than the left, and when he attempted to watch TV with one eye, he was surprised to discover that with the left eye alone, the pictures were hazy. Moreover, he could see better at the periphery than at the centre. He had no pain, distortion of the sight, and no double vision. These were very suggestive and significant pieces of information since they narrow down the clinical differential diagnosis further, and helps the examiner to design the clinical examination in a better way. The suggestive better peripheral vision, differential vision between the eyes and absence of distortion, pain, and double vision led to the impression that I need to focus in the anterior segment of the eye while conducting his examination (Age-Related Eye Disease Study Research Group, 2001). General Examination When I decided to carry out an examination, I felt that a patient with decreasing vision requires a complete examination to determine the cause of the visual decline. Therefore, I started to do a systematic examination. I performed a general examination of the eyes in good diffuse light, and I felt that it would lead me to the possible diagnosis, so later I can do a slit-lamp examination. The general examination began with the examination of the eyelids and the conjunctival sac. He was elderly and had some amount of sagging of the eyelids. On palpation, the lid margins did not demonstrate any swelling. There was no redness in the conjunctivae. The eyelashes were normal. There was no evidence of any inflammation or blepharitis in both the lid margins. In order to examine the conjunctival sac, it was necessary to expose the palpebral conjunctiva and the fornices. Due to age, his fornices were shallow. There was no crusting, follicles, conjunctival papillae, or pseudomembrane indicating chronic or acute inflammation contributing his diminished vision. I drew down his lower lid while he was asked to look towards the ceiling, and the lower fornix looked normal. This excluded any inflammation of the lower lid and swelling that can compromise vision temporarily. The upper lid was everted to examine the upper palpebral conjunctiva. These examinations ruled out conjunctival hemorrhage and any other adnexal disease that might have caused his visual impairment. Since there were no exudates and congestion, it could be safely assumed that there was no inflammation of the conjunctivae. Although there were no misplaced lashes, sometimes a lash irritates the eye to lead to blepharospasm, swelling, irritation, and even inflammation of the cornea leading to visual impairment. The global conjunctiva was normal looking, and there were no congestion whatsoever of the circumcorneal blood vessels. It was important since visibility and dilatation of the limbal plexus indicates inflammation of the cornea which if undetected and untreated may lead to serious irreversible visual impairment. There was no ciliary congestion since I did not notice any pink perilimbal injection supplemented by the dusky lilac tint of congestion of the anterior ciliary vessels. Although these do not have any separate diagnostic importance, it could rule out disease of inner eye such as inflammation of the iris or the sclera. His lacrimal apparatus in both eyes looked normal. Sclerae in both the eyes did not reveal any suggestive finding that can be ascribed to his progressive loss of vision in both the eyes (Harvey, 2003). Slit-lamp Examination It was decided next that I would examine his anterior half of the eye using a slit-lamp. This was required since in this setting, both his eyes would need careful and minute examination. This examination, as is known, utilizes the principles of focal illumination where a brilliant light is brought to focus as a slit by an optical system supported on a movable arm. I placed him in the patient's seat. He was a little apprehensive and fearful, and I decided to explain the operation of the machine to him and assured him that it would not hurt him, and this examination would diagnose his problems. The corneal surfaces of both the eyes were lustrous, bright, and transparent. This indicated healthy corneas. There was no evidence of irregularities indicating loss of substance. There was no evidence of opacities in the substance of the cornea with this examination even with minute examination with the slit-lamp. It is applicable for the whole thickness of the cornea in both the eyes. There was no punctate keratitis or keratic precipitates indicating inflammation of the uveal tract. Elimination of this possibility was important since these also are associated with some degree of edema of the corneal epithelium leading to compromised vision (Tasman and Jaeger, 2004). Anterior Chamber As expected with his age, both his anterior chambers were shallow, about 2 mm deep. I estimated the depth of the anterior chamber from the position of the iris. The irises were viewed through the corneas which were strongly refracting convex surfaces magnifying both the iris and the pupils. The depth of the anterior chamber in his case indicated that he had no closed angle glaucoma indicated by extreme shallowness or iridocyclitis indicated by abnormal depth. The anterior chamber depth appeared uniform in both the eyes, further excluding other relevant disorders such as iris bombe or tilting of the lenses. The contents of the anterior chamber appeared clear in both the eyes excluding inflammatory conditions of the uveal tract where due to increase in the permeability of the blood vessels, the aqueous may contain particles of protein or floating cells. These were important findings in his case since the absence of this aqueous flare being excluded through focusing the beam of the slit-lamp to a point, indicated absence of associated disorders of iris and uveal tract. This also obviated the mandatory need to examine the posterior aspect of the cornea (Tasman and Jaeger, 2004). Iris Moving further, the iris in both the eyes were examined. I noted the color of the iris and the clarity of its pattern. There was no color differentiation, ill-defined pattern, or patches of atrophy indicating iriditis, cyclitis, or glaucoma, all of which could contribute to visual impairment. There was no adhesion of iris or tremulousness (Tasman and Jaeger, 2004). Lens Next, the lenses were examined thoroughly. There were hazes in both lenses more at the center than in the periphery and more in the left than in the left. This obviously suggested lenticular opacities or cataract. The lens substances looked slightly milky, more pronounced on the left. On closer examination, these looked as gray-white patches. The condensation of the patch at the centre in both the eyes needed further examination of the pupils in a minute manner, since these could also be due to a pupillary exudates or even anterior polar cataract. On more minute examination through the slit-lamp, there was evidence that the opacities detected in his lens had patterns of triangular spokes with their apices toward the center. This confirmed the diagnosis of senile cataract in both his eyes. However, there were no while appearance over the whole pupillary areas, and therefore, these are not yet total cataracts. Since these were not yellow and there was no tremulousness in the iris, I concluded that the lenses were not yet shrunken and calcareous (Tasman and Jaeger, 2004). Conclusion In this experience of mine where I examined the anterior segments of both the eyes in this elderly person, as I reflect, I find the utility and necessity of a systematic examination of the eyes in any visual complaints. My clinical diagnosis thus far was cataract in his both eyes without any other impairing condition that needs immediate attention. However, this examination does not include further examination of his eyes in the posterior segments, and any condition present there cannot be ruled out with certainty with my examination. This was a great opportunity to apply academic knowledge in practice; however, it must be acknowledged that inexperience made me a little shaky, and that was sensed by the patient, and it took a little time for me to gain his confidence. Next time, if I am to do such a test, I will be more equipped to undertake this examination. This was a learning experience for me, where my academic learning on this topic was consolidated. There were no ethical, political, or social issues involved in this process. Reference List Age-Related Eye Disease Study Research Group, (2001). A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss. Archives of Ophthalmology; 119:1417-1436. Harvey PT., (2003). Common eye diseases of elderly people: identifying and treating causes of vision loss. Gerontology; 49:1-11. Quillen DA., (1999). Common causes of vision loss in elderly patients. American Family Physician; 60:90-108. Tasman W, Jaeger EA, eds. (2004). Duane's Clinical Ophthalmology. Philadelphia: Lippincott Williams & Wilkins; 2004. "Diseases of the Lens" in Volume 1. Read More