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Essentials of Ophthalmology
Vikram. D Durairaj, M.D.Associate Professor of Ophthalmology and Otolaryngology/Head and Neck Surgery
Residency Director, Dept. of OphthalmologyFellowship Director, Oculoplastic and Orbital SurgeryRocky Mountain Lions Eye InstituteUniversity of Colorado Denver School of Medicine
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Learning Objectives
At the conclusion of this presentation, the participant should be able to:
• Understand how to perform the basic eye exam
• Understand the differences between sight-threatening disorders and those that can be managed safely by the primary care physician
• Diagnose common ophthalmic disease
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The basic eye examThe tools:
visual acuity chart (can be your near card)
near card (has pupil sizes & ruler)
bright light (can use your direct ophthalmoscope)
direct ophthalmoscope
tonopen*
slit lamp*
eye drops: topical anesthetic, fluorescein dye, dilating drops
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The basic eye exam
History & physical
History: glasses, contacts, surgery, trauma,
Symptoms: foreign body sensation (surface problem), itch (allergy), photophobia (uveitis), diplopia (orbital or CN problem), flashes or floaters (retina problem), color vision or distortion (retina problem)
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The basic eye exam
**
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The basic eye examVisual acuityPupilsAlignment & Motility Visual fields (VF)Intraocular pressureExternal exam: lids and lashes, conjunctiva, sclera, cornea, anterior chamber, iris, lensDilated fundoscopic exam (DFE): optic nerve, vessels, macula, periphery
VITALS
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Visual acuity
Typically measured by Snellen acuity but there are many optotypes (letters, tumbling E, pictures)
May be tested at any distance
Recorded as fraction (numerator is testing distance, denominator is distance at which person with normal vision would see figure)
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Visual acuity
Measured without & without glasses (Vacc & Vasc), want to know best corrected acuity
Occlude one eye, children need to be patched
20/20 to 20/400, CF (counting fingers), HM (hand motion), LP (light perception), NLP (no light perception)
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Visual acuityThe pinhole (PH) exam can show refractive error
Need a pinhole occluder
Central rays of light do not need to be refracted
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Sensory visual function
Stereopsis (perception of depth), contrast sensitivity, glare, color vision
The red desaturation test
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Pupillary examPupil size - measure with pupil gauge on near card
Anisocoria should be recorded under bright and dim light (greater than 1 mm is abnormal)
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Pupillary exam
Relative afferent pupillary defect (RAPD) or Marcus Gunn pupil (has nothing to do with size of pupils but the comparitive reaction to light)
Detected with swinging flash light test
Indicates unilateral or asymmetric damage to anterior visual pathways (optic nerve or extensive retinal damage)
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Pupillary exam: APD
sft.jpg
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Ocular alignment & motility
Strabismus is misalignment of the eyes
Important to recognize in children to prevent development of amblyopia
Phoria is latent tendency toward misalignment (shows up sometimes)
Tropia is manifest deviation (present all the time)
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Ocular alignment & motility: corneal light reflex
Normal or straight
Exotropia (out)
Esotropia (in)
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Ocular alignment & motility: corneal light reflexBe aware of pseudoesotrpoia in children with epicanthalfolds
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Ocular alignment & motility: cover testingCover-uncover or alternating cover testing can reveal strabismus as non-occluded eye fixates on object
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Ocular alignment & motilityElevation, depression, abduction, adduction
0
0
0
0
-1
-3
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Confrontational visual fields
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Intraocular pressure
Measured by tonopen or palpation
Varies throughout the day, normal is 10-22 (start to worry when pressure is in the 30s and up)
Palpation may be useful if you suspect angle closure glaucoma (never perform in trauma)
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External examLids & lashes (head, face, orbit, eyelids, lacrimalsystem, globe)
Compare symmetry, use your ruler
Flip the lid; make a lid speculum
What am I seeing?
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Blepharitis
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Chalazion
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Chalazion: Treatment
• Warm compresses
• Lid hygiene if associated blepharitis
• Oral antibiotics?
• Cephalosporin
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Pre-Septal versus Orbital Cellulitis
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Cellulitis: PreSeptal vs. Orbital
• Children: most common
• Associated lid swelling (upper and lower)
• History of URI or sinus infection
• Both may have temp and elevated WBC
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Preseptal
• Eye Exam normal
• Patient does not appear “toxic”
• Can treat with oral antibiotics and close observation
• Unless in NEONATE!! Then hospitalize
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Orbital• A dangerous infection requiring prompt treatment
• Orbital Signs:
• Decreased vision
• Proptosis
• Abnormal pupillary response and motility
• Disc swelling
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Orbital Cellulitis: Ancillary Tests
• CT or MRI: Look for Sinus infection or orbital abscess
• Blood cultures
• Conjunctival swabs of no diagnostic value
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Orbital CellulitisTreatment
• Prompt drainage of orbital or sinus abscess
• Systemic IV antibiotics
• Haemophilus, Staph and Strep
• Semisynthetic PCN/ Cephalosporin
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Ptosis
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Ptosis
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Thyroid Eye Disease
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Proptosis
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Dermatochalasis
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Pre-op Photo
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Blepharoplasty
Pre-operative Photo 1 week post-operative Photo
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Dacryocystitis
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Naso-lacrimal ductObstruction
• Epiphora (Tearing)
• Recurrent bacterial conjunctivitis
• Often history of facial trauma
• TREATMENT: DCR
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Ectropion
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Entropion
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Trichiasis
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Conjunctiva & Sclera
Look at the bulbar (the eye) & palpebral (inside of the lids) conjunctiva
Injection & erythema; what is the distribution
Discharge; watery, mucous or membranous
What do I see?
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Scleritis or episcleritis
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Scleritis• Red painful eye with decreased vision
• Often associated with underlying collagen vascular disease
• RA, Lupus
• Diffuse, Nodular, Necrotizing forms
• REFER!!
• Requires systemic immunosuppression
• Indocin, Prednisone, Cyclosporin, Cytoxan
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RheumatoidArthritis
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SubconjunctivalHemorrhage
• Dramatic but harmless
• Sneezing,coughing, straining,eye rubbing
• Associated with anticoagulation
• Aspirin
• If no obvious cause and associated with bruising or repetive than:CBC, Platelet count, Bleeding time, PT/PTT
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SubconjunctivalHemorrhage
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Pterygium
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Pterygium• Latin for wing
• Benign fibrovascular tumor (UV induced)
• Elastoid degeneration (wrinkle)
• Often become inflamed
• Treatment:
• Artificial Tears, Sunglasses, Short term use of vasoconstrictors
• Refer if large or conservative Rx fails
• Conjunctival Autograft with Tisseel Glue
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Pingueculum
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Bacterial Conjunctivitis
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Conjunctivitis: Bacterial• Redness and mucopurulent discharge
• Minimal discomfort
• Vision minimally affected
• Treatment
• Will resolve without treatment
• Polytrim (polymixin-trimethoprim) q 2 hours the first day then QID for 1 week
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Gonoccocal Conjunctivitis
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Hyperacute Purulent Conjunctivitis
• Sudden onset with rapid progression
• Bilateral
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Viral Conjunctivitis
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Conjunctivits: Viral (EKC)• URI
• History of contact
• VERY CONTAGIOUS
• Sx’s: Photophobia, redness, watery discharge
• Bilateral but asymmetric
• Preauricalar node
• Treatment: None--Avoid Topical Steroids!!
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Allergic (Hay fever) Conjunctivitis
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Conjuntivitis: Allergic• ITCH
• SEASONAL
• Bilateral
• Mucopurlent discharge, no pre-auricular node
• Redness, Chemosis
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Allergic Conjunctivitis: Treatment
• Avoidance
• Associated with Dry Eye
• Wash eyes out with tears
• Cold Compresses
• Ocular antihistamines/mast cell stabilizers
• Patenol, Alocril, Zaditor
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CorneaClarity
Haze, or scars (including surgical)
Pterygium
Epithelium (use fluorescein dye & a cobalt blue filter to examine the epithelium for defects including punctateerosions, abrasions, ulcers, dendrites)
What do I see?
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Abrasion• History of Trauma or Contact Lens wear
• Very Painful: More pain nerves per mm than any other location
• Diagnosis:
• Drop of Proparacaine
• Flouroscein lights up epithelial defect
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Treatment• Relief of Pain and Rapid Visual Rehabilitation
• Antibiotic ointment, dilation, patch
• Bandage Contact lens
• With Antibiotic Drops
• Topical NSAID: Acular or Voltaren
• Recommend Follow-up (Infection)
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Patching
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Dry Eye• Postmenopausal women
• Sometimes associated with Arthritis
• Lupus, RA, Sjorgren’s
• Often related to climate/humidity
• Exacerbated by systemic medications
• Diuretics (HCTZ), antihistamines, and
anti-depressant
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Dry Eye: Symptoms
• Foreign body sensation
• Photophobia
• May complain of redness
• Associated blepharitis or allergic conjunctivitis is common
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Dry Eye: Diagnosis
• Schirmer’s test
• Fluorescein staining
• White, quiet eye is common
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Flourescein Staining
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Rose-Bengal
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Schirmer Test
Without anesthesia
• Measures reflex tear secretion
With anesthesia
• Eliminates stimulated tearing
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Dry Eye: Treatment• Artificial Tears: (Genteal,Theratears,Systane)
• Watch for preservative toxicity (BAK)
• Saturation therapy
• Preservative free drops
• If using more than 4/day
• Consider punctal occlusion or Restasis (Cyclosporine)
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Restasis
• Cyclosporine (.05%) in lipid vehicle
• Treats surface inflammation
• Inhibits T-cell infiltration of lacricmal gland
• Burns on instillation
• Administer BID (1 vial for the day)
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Dendrite
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Treatment of HSV Keratitis
• Topical Antivirals (Viroptic) Trifluridine
• Systemic Acyclovir or Famvir if immunosuppressed or extensive associated skin lesions
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Chemical Injuries• Acid or Alkali?
• Cation determines speed of penetration
• NH4+, Na+,K+,Ca++ (OH)
• Battery Explosions
• Chemical plus blunt force trauma
• Foreign body
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Chemical Injuries• Irrigate, Irrigate and Irrigate
• Topical anesthetic, 7th nerve block helpful
• Prognosis determined by:
• Type of chemical (acid vs. alkalai)
• pH
• Length of exposure
• TIME BETWEEN EXPOSURE AND IRRIGATION
REFER as soon as possible
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Corneal foreign body
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Corneal scar
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Anterior chamber
Clarity; measured by cells (counted) & flare
Depth
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Hypopyon
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Hyphema
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Cell & Flare
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Iritis/Uveitus• “Arthritis of the Eye”
• Associated with Collagen Vascular disease
• HLA-B27 associated
• Crohn’s disease, RA, Lupus
• Sx’s: Photophobia, Floaters, Red Eye, Pain, Decreased vision
• Circumlimbal flush
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Iritis
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Lens
Best examined through a dilated pupil
Senile cataracts can appear white or yellow
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Cataract
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Intraocular lens
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Dilated fundoscopic examRed reflex with direct ophthalmoscope
Dilate with phenylephrine 2.5% & tropicamide 1% (not used in infants)
Get close with the direct ophthalmoscope
Vitreous clarity (hemorrhage)
Nerve, vessels, macula & periphery with direct ophthalmoscope
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Papilledema
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Diabetic retinopathy
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Vitreous Hemorrhage
• Sudden onset of painless decrease in vision
• Floaters
• Often Diabetic
• Dx: No red reflex
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Macular degeneration