Eye Exam I

8/13/2019 Eye Exam I

1/87

The

OcularExamination

Karla J. Johns, M.D.


2/87

The Ocular Examination


3/87

The Ocular

Review of Systems


4/87

Ocular Review of Systems

Decreased vision

Severity

Onset Permanence


5/87


Diplopia

monocular vs. binocular

horizontal vs. vertical


6/87


Ocular Discomfort

Itching & burning

Asthenopia Photophobia

Severe pain


7/87


Other ocular symptoms

Floaters


8/87



Flashing lights


9/87

Ocular Review of Symptoms


Visual field defects


10/87

Ocular Medication History

Be sure to ask about eye drops

Many topical medications (eye

drops) have systemic effects


11/87


Visual acuity

Pupils

Motility Visual fields

External eye & anterior segment

inspection Red reflex and retinal examination


12/87

Visual Acuity


13/87

Visual Acuity

20/20The Snellen Fraction

Numerator: testing distance (20 ft) Denominator: distance at which a

normal eye can read the line of letters


14/87

Visual Acuity

Testing protocol

Patient 20 feet from eye chart

Chart well illuminated

Distance glasses, if any,should be worn

Cover non-tested eyecompletely

Record the line of letters ofwhich the patient canidentify more than half


15/87

Visual acuity

Standard abbreviations

V= visual acuity

N= near visual acuity OD = right eye

OS = left eye

OU = both eyes together

cc = with glasses

sc = without glasses

PH= vision through a pinhole


16/87

Visual Acuity

OD 20/20 1OS 20/30 + 2V


17/87

Visual Acuity If patient cannot read

the 20/20 line, measurevisual acuity through apinholeto determine

the potential vision ofthe eye

Useful in emergencysettings


18/87

Visual Acuity Through a

Pinhole


19/87

Visual Acuity

OD 20/60 Pinhole 20/30

OS 20/60 Pinhole no changeV


20/87

Visual Acuity

Assessing the visually impairedpatient

If unable to see the largest letter onthe chart, move patient closer to theeye chart (Change the numerator ofthe Snellen fraction)

OD 10/200OS 5/200V


21/87

Visual Acuity

Assessing the visuallyimpaired patient

HM = Hand Motion

CF = Count Fingers

LP = Light Perception

NLP = No Light Perception


22/87

Visual Acuity

Near visual acuity is a

common bedside test

Patient to wear reading

glasses, if any

Test at 14 inches,

one eye at a time

Recorded as Snellen equiv.or Jaeger point size (J)


23/87

Recording Near Visual Acuity

OD 20/40

OS 20/20

-or-

OD J2OS J1

N

N


24/87

Pupils Part of both the eye exam and the

neurologic examination

Dim the room lights

Ask the patient to look in the distance Inspect the size, shape and symmetry of

the pupils

Anisocoria =

unequal pupils


25/87

Pupils

Pupillary Light Reflexes


26/87

Pupils Test pupillary light reactions

Direct

Consensual


27/87

Pupils Test for afferent pupillary defect

(RAPD, or Marcus Gunn pupil)with swinging flashlight test


28/87

Swinging Flashlight Test

Normal findings: the pupils bothconstrict when you swing the flashlight


29/87

Swinging Flashlight Test Abnormal Finding: thepupilsdilate

when you swing the flashlight into oneof the eyes, but constrictwhen youswing the flashlight into the other pupil


30/87

Swinging Flashlight Test

A relative afferent pupillary defect(RAPD), also known as a MarcusGunn pupil, is a clinical sign of anoptic nerve or diffuse retinal lesion

Please remember this forever


31/87

Pupils

Test for accommodative (near)reflex


32/87

Pupils

Summary of pupil exam

Inspection

Direct & Consensual light reaction

Swinging flashlight for RAPD

Accommodative response


33/87

Motility examination


34/87


A part of both the ocular exam andthe neurologic examination


35/87

Motility examinationEOMs ennervated by cranial nerves III, IV

and VI


36/87


Corneal light reflex


37/87

Motility examination Examples of strabismus seen with

abnormal corneal light reflexes


38/87

Motility examination Types of strabismus


39/87

Motility examination Assess extraocular movements

(Look for smooth conjugate movements in allfields of gaze)


40/87

Motility examination Examples of abnormalities of

extraocular movements

Left eye cannotabduct Restricted upgaze of left eye


41/87

Ocular Motility

Summary of ocular motilityassessment

Corneal light reflexes

Assessment of extraocularmovements


42/87

Ocular Motility

An additional test

Cover-uncover test


43/87

Visual Fields Part of both the ocular examination

and the neurologic examination


44/87

Visual Fields

Confrontation visual field testing You should be at eye level with the seated

patient, 2 3 feet away

Patient occludes one eye

Ask the patient to look at your eye

Close your left eye to test the patients righteye, and close your right eye to test thepatients left eye

Present your fingers as a target, half-waybetween yourself & the patient, and ask thepatient when they come into view


45/87

Visual Fields Confrontation visual field testing


46/87

Visual Fields

Recording abnormalities of thevisual fields

Normal Bitemporal hemianopsia Visual loss

in right eye


47/87

Inspection of the External Eye

and the Anterior segment


48/87

Inspection of the External Eye

and Anterior Segment1. Eyelids

2. Conjunctiva & Sclera

3. Cornea4. Anterior chamber

5. Iris

6. Lens


49/87


50/87

Inspection of the External Eye and

Anterior Segment Other diagnostic techniques Eversion of the upper lid to find

foreign body

Grasp lashes and place

Q-tip 1 cm from lid

margin

Flip eyelid margin

over Q-tip


51/87

Inspection of the External Eye andAnterior Segment

Other diagnostic techniques

Eversion of the upper eyelid to findforeign body


52/87

Red Reflex and Retinal

Examination


53/87

Direct Ophthalmoscope

Provides a monocular 15X view ofthe retina

Parts of the

ophthalmoscope:

Viewing aperture

Focus wheel

Aperture wheel


54/87

The Focus Wheel

Plus lenses (blackor greennumbers)that correct hyperopia (far-sightedness)

Minus lenses (red) that correctmyopia (near-sightedness)

Plano = no lens

The lenses can correct the refractiveerror of the patient, the doctor, orboth


55/87

The Aperture Wheel

The apertures vary according tothe type of ophthalmoscope; mostare rarely used

The small round white light ismost useful for small pupils, andthe large round white light for

large pupils


56/87


57/87


58/87


The Normal Red Reflex


59/87

Direct Ophthalmoscope Examples of abnormal red reflex

Cataract (lens opacity) Intraocular Tumor


60/87


Technique for retinal examination

Darken the room

Have patient look straight ahead

Examine patients right eye with yourright eye, and left eye with left

Rest your thumb on the patients

brow to aid your proprioception


61/87


Technique for retinal examination Align yourself about 15 degrees

temporal to the patients line of sight

Slowly approach the patient, keepingthe pupil in view, moving the focuswheel closer to zero

When you are very close to the

patient, the retina will come intofocus


62/87


Technique for retinal examination


63/87

Panoptic Ophthalmoscope


64/87

Panoptic Ophthalmoscope


65/87


Dilating drops make the retinalexamination much easier

Dilating drops are not routinelyused by non-ophthalmologists butmay be used in specificcircumstances


66/87


Good dilating drops to use:

Neosynephrine 2.5 % (phenyleprine)

Mydriacyl .5% or 1 % (tropicamide)

Dont use Atropine or Neosyneprine10%

Direct Ophthalmoscope:


67/87

Direct Ophthalmoscope:Contraindications to dilating the

pupil Patient isneurologicallyunstable

Patient may have anopen eye injury


68/87


Contraindications to dilating the pupil

The patient has a shallow anterior chamber

(Risk of the iris blocking the flow of

aqueous and causing acute pressure rise)

(This is rare; usually in elderly patients)


69/87


The tangential flashlight test torule out a narrow anterior chamber


70/87


Technique for retinalexamination

When a vessel comes intoview, follow a bifurcationas it points you toward theoptic disc

When the disc comes intoview, adjust your focus


71/87


Systematic examination of the retina

Optic disc

Retinal vessels

Retinal background Macula


72/87


Field of view is smaller thantextbook photographs

Field of view:


Field of view:

Fundus photograph


73/87

Optic Disc Assessment

Sharpness of the disc margin Normal nasal margin

may be slightly blurry

Color of the disc Normal is orange

or pinkish

Contour of the disc Should be flat

with central cup


74/87


Pigment crescents and white scleralcrescents are normal variants


75/87


Optic disc should be flat

Elevation of the disc isseen more easily in vivo

than in photographs Bilateral optic disc

swelling from increased

intracranial pressure ispapilledema

Normal flat disc

Swollen disc


76/87


Optic cup should behalf the width of thedisc (CD ratio)

A large CD ratio issuggestive ofglaucoma


77/87


When describinglesions ordistances, the

optic discdiameter (DD) is aconvenient

ruler

Pigmented lesion 1 DDfrom the disc

The optic disc is about 1.5

mm in diameter


78/87

Retinal vessel assessment

From the disc, followeach arcade of vessels(a paired artery &

vein) peripherally Look for smooth,

gradual tapering


79/87

Retinal Vessel Assessment:Distinguishing arteries & veins

Arteries

Bright red

Narrower

Bright light reflex

Veins

Darker red

Wider

Inconspicuous orabsent light reflex

Retinal Vessel Assessment


80/87

etinal Vessel ssessment Abnormal vessel caliber changes:

arteriovenous crossing changes

A-V Nicking

A-V Banking

Example of A-V

banking & nicking

Knick


81/87

Assessment of retinal

background Normal variation

of retinal

background

pigmentation


82/87

Assessment of retinal

background View retinal

background

to make sure thereare nohemorrhages,exudates, or otherabnormalities

Abnormal retinal backgroundwith hemorrhages & exudates


83/87

Assessment of the maculaTwo ways to find the macula

1. Direct theophthalmoscope 2

disc diameterstemporal to the disc,or,

2. Ask the patient to

look at the light


84/87


85/87


Systematic evaluation of the retina

Optic disc

Retinal blood vessels

Retinal background

Macula


86/87


Visual acuity

Pupils

Motility Visual Fields

Inspection of the external eye and

anterior segment Red reflex and retinal examination


87/87


Tutorial today in Light Hall Prize awarded for best visual acuity in

the class of 2012 !

February 2010: More detailed

information about the retinal disease,external eye and anterior segmentabnormalities, and tutorial session atVanderbilt Eye Institute

Date post:	04-Jun-2018
Category:	Documents
Upload:	hello876
View:	221 times
Download:	0 times

Eye Exam I

Documents