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Anel Test

Topical anesthesia is given and dilatate the lacrimal punctum. Anel needle inserted in the
punctum and canaliculi lakrima. Spraying is done with normal saline. Asked whether the patient
feels fluid in the throat or seen whether the swallowing reflex occurs in patients. If its appear, it
means good excretory function of the lacrimal system. if its not appear, then there is a blockage
of the nasolacrimal duct.
Funduscopy Examination
1. Keep both yours and the person's eyes
2. Have the patient focus on a distant object
3. Look at right fundus with your right eye
4. Ophthalmoscope should be close to your eyes. Your head and the scope should move
5. Set the lens opening at +8 to +10 diopters. With the ophthalmoscope 12-15 inches from
the patient's eye, check for the red reflex and for opacities in lens or aqueous.
6. While adjusting the diopter setting, approach the patient more closely and systematically
inspect the disc, noting the color, shape, margins and cup-to-disc ratio.
7. Inspect the vessels, noting obstruction, caliber and arterial/venous ratio.
8. Note the presence of arterial/venous nicking and arterial light reflex.
9. Check the background by inspecting for pigmentation, hemorrhages and hard or soft
10. Next, try to identify the macula.
o Have the patient look at light
o Tropicamide 0.5% - 1% (Mydriacyl)

Blue eyes more sensitive, lasts longer

Start with 0.5% concentration

o Phenylephrine hydrochloride 2.5% (Ak-Dilate)

Shorter acting

Contra-indications to use
o Shallow anterior chamber OR angle-closure Glaucoma
o Following pupillary signs after Head Injury
o Iris supported intraocular lens implantation

(square/hexagonal pupil 'sputnik')

We will find :

o margins are sharp
o color: yellowish orange to creamy pink
o shape: round or oval
o Cup to disc ratio: less than half

o AV ratio
o AV crossing: no indentation
o No arterial light reflex

Fundus background
o No exudates or hemorrhages
o color : red to purplish


o macula is located 2.5 disc distance temporal to disc

o no vessels are noted around Macula
o it may be slightly pigmented
Normal fundus: Vessels emerge from nasal side of disc. Arteries are narrower than veins.

Pathological Optic Cupping : Note cup-to-disc ratio at least 0.8 (physiologic limit of 0.5).

Optic Disk Edema

The optic disc is elevated and its surface is covered by cotton wool spots (damaged axons) and
flame hemorrhages (damaged vessels). Four I's: increased intracranial pressure (papilledema),
infarction, inflammation, infiltration (by cancer).

Arterio-Venous (AV) Nicking

Chronic hypertension stiffens and thickens arteries. At AV crossing points (arrow) arteries indent
and displace veins.

Cotton Wool Spots

Caused by microinfarcts. Exploded ganglion cell axons extrude their axoplasm into retina. Long
DDx: hypertension, diabetes, HIV, severe anemia or thrombocytopenia, hypercoagulable states,
connective tissue disorders, viruses, and others.

Emboli and Infarcts

Small fleck a Hollenhorst plaque caused from platelet/fibrin/cholestorol embolus. Resulting in

an infarct (gray area above and right of the plaque).

Roth Spot
Pale-centered hemorrhage. Caused by several conditions, not only bacterial endocarditis.