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opto shosho

on 23 December 2014

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Transcript of PEN TORCH


An aperture present in the center of the iris.
The size of the pupil determines the amount of light that enters the eye.
The pupil size is controlled by the dilator and sphincter muscles of the iris.
Normally there is one pupil in each eye.
Rarely, there may be more than one pupil. This congenital anomaly is called POLYCORIA.


Medical devices developed in our time and spread dramatically, including simple and complex .The aim of human service and provide facilities in front of service.Today we'll talk about a simple device, namely "ophthalmic pen light" , "pen torch" , "pen light".

Is optometric instrument to observe and scan the eye surface and its attachement quickly and easily.
Its should be red or yellow color not white.
Clinical Examination.
Afferent pathway defects.
Efferent pathway defects.
Abnormalities of pupillary reflexes.
Swinging Flashlight Test.

BY: Myada wael Gharbyia
Shoroq Sufyan Alghoul
Maram Awny Baroud
Mysaa Reyad Jendeya
Saba Samir Alzatmah
TO: Dr.Hamed TM Al-khodari

Anterior segment examination (by torch)
Inspect the cornea for opacities
(number, site, size, density,adherence to the iris and vascularization)
Inspect the iris
for color, iridectomies and atrophy
Inspect the pupil
for site, size, shape, regularity and color
Inspect the lens
for color and position
Torch: General appearance, facial asymmetry, iris, pupil size.

The cornea opacities
The iris : color and atrophy
The pupil for site,size,shape and color regularity
These pen light commonly used by ophthalmologists,
becouse its simplicity, portability and availability besides its adequate prices.
It is considered to be first line examination method by most examiners in eye care field.
The lens for color and position

Normally, pupil is placed almost in the center (slightly nasal) of the iris.
Rarely it may be congenitally eccentric.

Normal pupil size varies from 2.5-4mm depending upon the illumination.
- Miotic pupils are less than 2mm
- Mydriatic pupils are greater than 7mm

Diameter of the pupil size should be estimated in light, using either a normal room light or a hand held transilluminator.

It should then be assessed in darkness using the dimmest possible room light and then during near stimulation using an accommodative target to achieve maximum constriction of pupils.

The size depends on :
Age : Smaller in infants and elderly.
Sleep : Smaller due to parasympathetic dominance.
Psychology of individual – smaller in placid people.
Refraction : Hyperopes have smaller pupils .
Colour : Darker iris have smaller pupils .

Isocoria : Normally the two pupils are equal in size. A slight (one-tenth of a millimeter) anisocoria is present in a significant percentage of normal pupil.
Anisocoria : Difference in pupillary diameter of 2 eyes of the same individual by 0.3mm or more.
The most common cause of anisocoria is central anisocoria (occurs in 20% of normal individuals) and is due to asymmetric supranuclear inhibition of Edinger-Westphal nucleus.
It can be easily distinguished from other abnormal pupils by normal reactions to bright light, near response and lesser degree of inequality.

Normal pupil is almost circular in shape
D - shaped in iridodialysis.
Festooned on dilatation if there is posterior synaechia.
Pear shaped in cases of leukoma adherent.
Key hole shaped in cases of sector iridectomy.
Oval in cases of acute congestive glaucoma, severe brain disease.
Tadpole shaped pupils results from sector dilatation observed sometimes in Horner’s syndrome.
Scallop shaped pupils due to sector atrophy of the iris are seen sometimes in amyloidosis and neuropathy of short ciliary nerves.

Posterior synechiae

Adherent leukoma


Normally, it is greyish black.
It becomes jet black in aphakia
Greyish white: -  cataract.
Brown in: nuclear cataract.
Whitish: - Retinoblastoma and pseudo gliomas .
Yellowish: - vitreous abscess (endo and panophthalmitis).
Greenish: - Acute congestive glaucoma.
Reddish in albinism.

The term leukocoria means whitish pupil.
Its cause are classified into:
A. Glioma (the old name of retinoblastoma).
B. Pseudo glioma (any other cause of leukocoria) as:
- Congenital cataract.
- Cyclitic membrane.
- Retinopathy of prematurity (retrolental fibroplasia): it occurs due to oxygen toxicity of premature infants.
- Retinal detachment.
Pen torch method

The simplest method of assessing ACD is,by shining a pen torch into the patient’s eye from the temporal canthus such that the pen torch lies in the same plane as the eye. In the case of a deep anterior chamber, the iris lies flat and the whole,iris will be illuminated. In the case of a very shallow anterior chamber the iris lies forward, blocking some of the light and very little of the iris is illuminated.Based on the amount of eye illuminated the ACD can be graded.

For many patients, the squint is obvious on examination. A simple screening test for strabismus is the Hirschberg test. This can also be used to give an estimate of the degree of strabismus. A pen torch is shone in front of the patient's eyes and the light reflection should be in the same spot bilaterally. In the presence of a squint it is in different areas of each eye.


Muscle tissue of the iris consists of:
A) Sphincter pupillae
B) Dilator pupillae

The afferent pathway
The efferent pathway:
The Light Reflex
The light reflex consist of simultaneous and equal constriction of pupils in response to stimulation of one eye by light
Pupil constriction is elicited with extremely low intensities and is proportional within limits to both intensities and duration of stimulus.
we should note that the reflex is corneal reflex not red reflex.
Diagnosis of a squint
Direct and Consensual Reflex
Method of Examination


Caused by a complete optic nerve or retinal lesion leading to total blindness on the affected side.
Characterized by the following :
- The involved eye is completely blind (i.e no light perception).
- Absence of direct light reflex on the affected side and absence of consensual light reflex on the normal side.
- When the normal eye is stimulated, both pupils react normally.
- In diffuse illumination, both pupils are equal in size.
- The near reflex is normal in both eyes.

It is the paradoxical response of a pupil to light in the presence of a relative afferent pathway defect (RAPD).

Caused by an incomplete optic nerve lesion or a severe retinal disease.

It is best tested by ‘swinging flashlight test’

Swinging Flashlight Test
To perform this test, a bright flashlight is shone on to one pupil and constriction is noted. Then the flashlight is quickly moved to the contralateral pupil and response is noted.
This swinging to and fro of flashlight is repeated several times while observing the pupillary response.
Normally, both pupils constrict equally and the pupil to which light is transferred remains tightly constricted.
In the presence of RAPD in one eye, the affected pupil will dilate (paradoxical response) when the flashlight is moved from the normal eye to the abnormal eye.
This response is called Marcus Gunn Pupil.
It is the earliest indication of optic nerve disease even in the presence of a normal visual acuity.

Horner’s syndrome

Retinopathy of prematurity (retrolental fibroplasia): it occurs due to oxygen toxicity of premature infants.
- Retinal detachment.
- Endo and panophthalmitis.
- Coat´s disease
- Coloboma
- Retinal dysplasia
- Norrie´s disease

Normal eye
Defect eye
Characterized by absence of both direct and consensual light reflex on the affected side (say right eye) and presence of both direct and consensual light reflex on the normal side (i.e left eye).

On the affected side, near reflex is also absent and pupils remains fixed and dilated.

Causes Of RAPD
Optic neuritis
Anterior ischemic optic neuropathy
Optic Nerve Tumors
Orbital Diseases
Ocular Ischemic Syndrome
Central serous retinopathy or cystoid macular edema
Retinal detachment
Chiasmal compression
Optic tract lesion   

Efferent Pupillary Defect Etiologies
Iris sphincter damage from trauma.
Third-nerve palsy.
Traumatic iritis, uveitis, angle-closure glaucoma, recent eye surgery.
Pharmacologic agents:
Unilateral use of dilating drops.
Atropine, cyclopentolate, homatropine, phenylephrine
Sympathomimetic agents: ephedrine, cocaine, ecstasy.





- Endo and panophthalmitis.
- Toxocariasis
- Coat´s disease
- Coloboma
- Retinal dysplasia
- Norrie´s disease
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