Week 2: The external exam

Question 1

What order should you

perform your slit lamp routine?

Answer 1

From from anterior structures to the most posterior

Question 2

What is the procedure for the first structure?

Answer 2

Eyelids

• sweep across lid margins and inspect for inflammation, growth, blepharitis
• look for lids turning inwards (entropion)
• look for lids turning outwards (ectropion)

Question 3

What is the procedure to Bulbar conjunctiva assessment?

Answer 3

Examine the bulbar conjunctiva for vascular injection, engorgement or
irregularities. Temporal, nasal, superior, inferior.

Pay particular attention to the limbal conjunctiva, examine the vasculature to
see if any extend into the cornea

While the patient looks up, evert the lower lid and inspect the tarsal
conjunctiva for inflammation, follicles, papillae. In this position examine the
inferior lid margin and meibomian glands.

If indicated, evert the upper eye lid with a cotton bud and examine. Be
mindful that the lid and cornea will dry out quickly and you do not want to
cause any discomfort to your patient

Question 4

What are you assessing for in the tear fim assessment?

Answer 4

Excess debris/make up 
Mucous threads
Corneal filaments
Superficial corneal staining
Lipid abnormalities
mucin or aqueos defiency

Question 5

What is the technique for cornea assessment?

Answer 5

Begin with parallelepiped (2-4mm) As you sweep horizontally you can observe
both direct, indirect and iris retroillumination.

Inspect layers anterior to posterior – epithelium, stroma, endothelium.

Use high magnification and specular reflection to view the endothelium

Use sclerotic scatter to visualise opacities in the cornea

Estimate anterior chamber depth

Question 6

What are some findings that can occur in the cornea?

Answer 6

Findings may include: Dystrophies, degenerations, inflammatory conditions, pigment
deposition, scars, abrasions. Each layer and lesion type is best seen with varying
techniques, as well as with vital dye staining.

Question 7

What is the procedure to Anterior chamber assessement with a slit lamp?

Answer 7

The AC is examined by means of a conical beam at the smallest aperture,
highest magnification, and the darkest room possible to widen the pupil and
increase contrast.

Inspect for inflammatory cells, flare, using both direct and indirect
illumination.

Question 8

What illumation should you use when grading inflammation?

Answer 8

(used 1mm x 1mm for grading inflammation)

Question 9

What is the procedure for assesement of the iris and lens?

Answer 9

Parallelepiped to examine the iris and lens

The crystalline lens is investigated with an optic section. A wide offsetbetween illumination and observation systems is best, but often limited by pupil size.

Question 10

What is the procedure for assessement of the Anterior vitreous?

Answer 10

A narrow parellepiped and a 10-30 degree offset will
allow you visualise the anterior vitreous. Pupil dilation
may be required, especially in older patients.