undergraduate lecture 5-general ophthalmic evaluation and management
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Dr Mazhry frcsfcps
Introduction to General Ophthalmic Evaluation and Management
Dr Zia-Ul-MazhryFCPS(Pak) FRCS(Edin)
FRCS(Glasgow) CIC Ophth- (UK)
Associate ProfessorHead of Eye Department
Central Park Medical College amp WAPDA Teaching Hospital Complex Lahore
Pakistan
Dr Mazhry frcsfcps2
For Education purpose only
bull No financial disclosure neededbull Images and material copied from different
Internet resources for teaching of undergraduate ophthalmology students
Dr Mazhry frcsfcps3
Intended Learning Outcomes
Practical amp Professional Skillsndash Perform examination of adnexa of the eyendash Measure visual acuityndash Test visual fieldndash Test extra ocular muscle motilityndash Examine pupillary light reflexndash Examine anterior segment of the eye
Dr Mazhry frcsfcps4
Intended Learning Outcomes Practical amp Professional Skills
ndash Practice Basics of health and patientrsquos safety and safety procedures during practical and clinical years
ndash Communicate clearly sensitively and effectively with patients regardless of their social cultural or ethnic background
ndash To formulate a working ndash To decide about Additional laboratory or imaging
studies to confirm the clinical diagnosis ndash To initiate a proper treatmentreferral plan can be
instituted
Dr Mazhry frcsfcps
Disc Quiz- Match with Correct labels
MCQ-1
MCQ-3
MCQ-2
MCQ-4
Normal Optic Disc
A Hypertensive PapillopathyB Disc swellingC Optic AtrophyD Glaucomatous Cupping
Dr Mazhry frcsfcps
Retina Quiz- Match with Correct labels
MCQ-5
MCQ-7
MCQ-6
MCQ-8
Normal Retinal Appearance
A CRVOB Retinitis PigmantosaC Myopic DegenerationD Diabetic Retinopathy
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MCQ-9
bull Test being performed is
a Applanation tonometeryb Schiotrsquos tonometeryc Air Puff Tonometeryd Digital Tonometery
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MCQ-10
bull Test being performed is known as
a FFAb CT scanc B scand MRI
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bull Physicians who will make the effort to learn develop and practice the skills required for ocular examination will be rewarded by observing many important clinical findings that will often assist in diagnosing and treating their patients The reverse is also true Those who forego an ocular examination may miss physical findings vital to the correct diagnosis and thus proper treatment of the patientrsquos ocular or systemic diseases
Introduction
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Contextbull Eye complaints are common in
general practice15 of all consultations1
bull GP ideally placed to triage ndash what can be reassured and what needs referral
1) SHELDRICK JH WILSON AD VERNON SA SHELDRICK CM Management of ophthalmic disease in general practice Br J Gen Pract1993 43(376) 459ndash62
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Requirements for a structural examination of the eye
1 Snellen Eye Chart 2 Near Vision Eye Card 3 Bright Penlight or Transilluminator 4 Direct Ophthalmoscope 5 Sterile Fluorescein Strips 6 Sterile Irrigating Solution
Optional accessories include a pinhole viewer various occluders and cotton-tipped applicators The ophthalmoscope is the only expensive instrument required for the examination All other equipment is quite inexpensive
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Toolsbull Snellen chartbull Pinholebull Torch with blue filterbull Fluoresceinbull Red pinbull Drugs
ndash Topical anaestheticbull Proxymetacaine
ndash Topical mydriaticbull Tropicamide (short-acting)bull Cyclopentolate
bull Ophthalmoscope
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Why Examine the Eyes
bull 75 of our sensory stimuli arrive via the eyesbull examination of the eyes can lead s to observe
many types of abnormalities of the visual system cranial nerves and brain
bull An opportunity for direct examination of living tissues
bull Ocular vs systemic and systemic vs oculr associations
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A Ocular Complaints
bull Ocular complaints can be grouped into six large categories ndash (1) visual complaints ndash (2) pain in and around the eye ndash (3) a red eye ndash (4) flashes and floaters ndash (5) diplopia or ndash (6) trauma to the eye andor orbit
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Dr Mazhry frcsfcps
A Ocular ComplaintsVisual Complaints
How to Examine the Eyes History
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A Ocular Complaints
bull Pain in and around the Eye
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A Ocular Complaints3 Red Eye
Conjunctivitis Iritis (Anterior Uveitis) Angle Closure Glaucoma
Visual Acuity Normal Normal or Slightly Reduced Decreased
Pain Irritation (Mild) Mild to Moderate Severe
Photophobia No Severe Variable
Discharge Yes Purulent Tearing Tearing
Pupil Normal Small Sometimes Irregular
Mid-Dilated and Fixed
Anterior Chamber Deep Deep Shallow
Cornea Clear Clear Cloudy
Systemic Symptoms None None Nausea andor Vomiting
How to Examine the Eyes History
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4 Flashes and FloatersA Ocular Complaints
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A Ocular Complaints
bull 5 Diplopia (Double Vision)ndash Confusion vs diplopia
bull True diplopia always binocularndash Vertical vs horizontalndash Associated Neurological Sympromsndash HO Vascular Diseases
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How to Examine the Eyes History
A Ocular Complaintsbull 6 Trauma to the Eye andor Orbit
ndash Naturendash Circumstancesndash Intactness of globendash Possibility of intraocular foreign body
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How to Examine the Eyes History
B History of Present Illnessbull The history of the patientrsquos present illness is
developed into a narrative that describes the development of the complaints over time
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How to Examine the Eyes History
C Past Medical Historybull patientrsquos past medical diseases bull surgeries bull and response to therapy
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How to Examine the Eyes History
D Family Historybull (1) glaucoma bull (2) cataracts bull (3) strabismus and bull (4) blindness
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How to Examine the Eyes History
E Medication Historybull Systemic
ndash Pastndash Present
bull Ocular ndash Pastndash Present
bull Allergies
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How to Examine the Eyes History
F Nutritional Historybull Vitamin A defficiencybull Alcoholicsbull Nutritional Optic Atrophy
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How to Examine the Eyes History
G Sexual History
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How to Examine the Eyes History
H Review of Systemsbull specific questions about organ systems
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A Clinical Anatomy Of The Eye
Anatomy Of The Ocular FundusExternal Anatomy Of The Eye
V How to Examine Eyes Physical Examination
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V How to Examine Eyes Physical Examination
B Visual Acuity
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Variations of Peeking by Patient - You Must Be Alert For This
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Light PL vsPR
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VARE 66
OD 2020With (cc) or Without correction (sc)
LE 66OS 2020
Visual acuity is documented in the chart in the following fashionOD is the abbreviation for Oculus Dexter (the RIGHT eye-RE) and OS is the abbreviation for Oculus Sinister (the LEFT eye-LE)
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Dr Mazhry frcsfcps
Dr Mazhry frcsfcpsMeasuring Visual Acuity of the Right Eye with the Pinhole
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V How to Examine Eyes Physical Examination
C Examination of the Eyelids and Orbit
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Bilateral Lid Retraction in a Young Patient With Graves Disease
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Note Proptosis of Left Eye Easily Seen by Viewing the Relative Positions of
the Eyes from over the Brow
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eyelids and the eyelashes are examined
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V How to Examine Eyes Physical Examination
Conjunctival Examination
D Examination of the Conjunctiva Sclera
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Exam
inati
on o
f the
upp
er
palp
ebra
l con
junc
tival
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Eversion of the upper lid is accomplished by following these steps
1) Explain to the patient what you are about to do This is not a painful examination but may induce squeezing in some patients
2) Instruct the patient to look down but keep both eyes open This is imperative for the success of the examination
3) Grasp the lashes of the upper lid in the center and pull downward Placing your thumb or a cotton-tipped applicator on the upper lid above the lid crease simultaneously pull up the lashes and push down the cotton-tipped applicator or thumb The lid should evert
4) Secure the lashes between your thumb and the patientrsquos brow to keep the lid everted while the examination continues
5) Study the exposed palpebral conjunctiva and carefully look for foreign material Prior use of fluorescein may assist in identifying light-colored materials such as sawdust
6) Upon completion of the examination release the upper lid The patient will usually blink returning the lid to its normal position If it does not return spontaneously instruct the patient to look up
Dr Mazhry frcsfcps
E Examination of the Cornea
bull Examining the cornea involves two observations ndash The first is to evaluate the overall clarity of the
cornea ndash the second is to examine the quality of the corneal
reflection
V How to Examine Eyes Physical Examination
Dr Mazhry frcsfcps
Dr Mazhry frcsfcps
Staining the tear film with fluorescein may help evaluate the conjunctival and corneal surfaces Fluorescein is usually applied from a sterile strip moistened with a drop or two of sterile irrigating solution If using the larger strips peel back the outer wrapper and tear off the strip so that about frac14 inch of the stained area of the strip remains adjacent to the unstained ldquohandlerdquo This amount of fluorescein should be sufficient for any examination
Dr Mazhry frcsfcps
The patient is instructed to look upward and the moistened strip gently touched to the lower lid margin The patient is asked to blink several times to spread the dye A Woodrsquos lamp or other blue filter is used to illuminate the ocular surface Areas where the epithelium is disrupted will take up the dye and stain a bright yellow-green when viewed with a Woodrsquos lamp or cobalt blue filter It is not necessary to wash the remaining fluorescein from the eye
Dr Mazhry frcsfcps
Do not use fluorescein if the patient is wearing soft contact lenses as this action will cause permanent staining of the lenses Remove the lenses and instruct the patient not to reinsert the contacts for at least 4 hours Patients with obvious corneal or scleral lacerations do not require the instillation of fluorescein to adequately evaluate their injuries
Dr Mazhry frcsfcpsHyphema
V How to Examine Eyes Physical Examination
F Examination of the Anterior Chamber
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Hypopyon
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Anterior chamber depth assessment
bull Likely shallow if ndash ge 23 of nasal iris in shadow
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Examination of the Depth of Anterior Chamber
Dr Mazhry frcsfcps
Pupillary Size
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Dr Mazhry frcsfcps
Dr Mazhry frcsfcps
Dr Mazhry frcsfcps
Pupillary Examination
bull Direct penlight into eye while patient looking at distance
bull Direct ndash Constriction of ipsilateral eye
bull Consensual ndash Constriction of contralateral eye
Dr Mazhry frcsfcps
Direct and Consensual Light Reflex
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Consensual Light Reflex This reflex is checked in the same way as the direct pupillary light reflex but observe the reaction in the other eye A normal consensual response in an eye with a nonreactive pupil indicates the presence of a severe afferent arc defect on the side with the nonreactive pupil A nonreactive pupil that fails to respond to consensual stimulation has a defect in the efferent arc of the eye with the nonreactive pupil The cause could be a palsy of cranial nerve III or the result of structural (traumatic or surgical) or pharmacologic changes in the pupil
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Relative Afferent Pupillary Defect (RAPD)
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Abnormal RAPD
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Accommodative (Near) Pupillary Reflex
Examination of the near reflex is not required for every pupil examination If however the direct light response is absent in one or both pupils then the accommodative (near) reflex must be evaluatedThe patient fixates on a distant target The physician holds an object in the patients midline and then asks the patient to look at this near target Three actions should occur
1 Miosis (constriction) of the pupils2 Convergence (the two eyes move inward)3 Accommodation (the cilary muscle contracts
focusing the lens at the near object)
Dr Mazhry frcsfcps
V How to Examine Eyes Physical Examination
H Examination of the Extraocular Muscles
Two characteristics of the extraocular muscles must be evaluated ocular alignment and conjugate movement of the eyes (ocular versions)Ocular AlignmentAlignment of the visual axes is tested by one of two methods (1) light reflex test or (2) alternate (cross) cover test
The alternate cover test is more sensitive but requires a higher level of patient cooperation Patients with poor or no vision in one eye cannot be tested accurately with the alternate cover test
Dr Mazhry frcsfcps
Ocular Motility
Rt superior rectusLt inferior oblique
Lt superior rectusRt inferior oblique
Rt lateral rectusLt medial rectus
Lt lateral rectusRt medial rectus
Rt inferior rectusLt superior oblique
Lt inferior rectusRt superior oblique
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Corneal Reflection Test
Light Reflex Test Hirchberg test
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Alternate (Cross) Cover Test
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Alternate Cover Test Demonstrating OUTWARD Motion of Eyes During Testing Indicating ESO-Deviation of Eyes (Patients Eyes Turn INWARD) Simulation With Prism
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Alternate Cover Test Demonstrating INWARD Motion of Eyes During Testing Indicating EXO-Deviation (Patients Eyes Turn OUTWARD) Simulation With Prism
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Alternate Cover Test Demonstrating Vertical Deviation (Left HYPERTROPIA - Left Eye Higher) Simulation With Prism
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Actual Patient With ESOphoria
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Actual Patient With EXOphoria
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Ocular Versions
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Ocular Ductions of Right Eye(Four Directions)
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Example of PureHorizontal Diplopia- Note
Continuity of - Shoreline
Evaluation of Patient with Diplopia
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Evaluation of Patient with Diplopia
Example of Pure Vertical Diplopia
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Evaluation of Patient with Diplopia
Example of Oblique Diplopia
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Patient with Right Sixth Nerve Palsy
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Example of Third Cranial Nerve Palsy on the Right Side
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Example of a Left Fourth Cranial Nerve Palsy
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V How to Examine Eyes Physical Examination
I Confrontation Visual Fields
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Measurement of IOP
bull bullDigital methodbullIndentation tonometry (schoitz)bullApplanation tonometry (Gold-man)bullNon-contact (air) tonometry
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V How to Examine Eyes Physical Examination
J Estimation of the Intraocular pressure by Tactile Tension (TT)
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Intraocular Pressure Measurement
bull Range 10 - 22
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V How to Examine Eyes Physical Examination
K Examination of the Red ReflexExamination of the red reflex is accomplished with the direct ophthalmoscope The instrument is held in the same fashion as for viewing the fundus but the eye is viewed from a distance of between arms length and 8 - 10 inches The lens wheel will need to be focused at about +2 (green or black numbers) for a distance of 20 inches up to about +5 at a distance of 8 inches The object is to focus the ophthalmoscope at the level of the pupil rather than at the level of the fundus While this is best done with a dilated pupil an examination carried out in a dark room will often lead to satisfactory viewing of the red reflexThe red reflex of each of the patients eyes should be viewed and the quality of the red reflex compared Abnormal shadows or differences in the red reflex between the two eyes require consultation with an ophthalmologistBelow are several examples abnormal appearances of the red reflex in various disease statesCataract - NuclearCataract - Posterior SubcapsularCataract - CorticalLeukocoria - Retinoblastoma
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Examination of the Red ReflexAbnormal Red Reflex Due To Nuclear Cataract
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Examination of the Red ReflexAbnormal Red Reflex in Patient with Posterior Subcapsular Cataract
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Examination of the Red ReflexAbnormal Red Reflex in Patient with Cortical Cataract
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Examination of the Red ReflexAbnormal Red Reflex in Patient with Cortical Cataract
Leukocoria Right Eye (upper photograph) caused by RetinoblastomaLeukocoria Left Eye (lower photograph) caused by Retinoblastoma
Dr Mazhry frcsfcps
You may set the lens wheel to ldquo0 (zero) to start
Proper Way to Hold the Direct Ophthalmoscope in the Left and Right Hands
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Proper Technique for Examination of the Right and Left Eye
With the Direct Ophthalmoscope
Dr Mazhry frcsfcps
Dr Mazhry frcsfcps
Five parameters of the disc are observed and recorded1 Color ndash Is the disc normal pink hyperemic or pale
Dr Mazhry frcsfcps
Five parameters of the disc are observed and recorded2 Contour ndash Is the disc elevated or flat
Dr Mazhry frcsfcps
Five parameters of the disc are observed and recorded3 Circumference ndash Is the disc margin sharp or blurred
Dr Mazhry frcsfcps
Dr Mazhry frcsfcps
Five parameters of the disc are observed and recorded4 Cupdisc ratio ndash What is the relationship between the cup size and the disc size
Dr Mazhry frcsfcps
Five parameters of the disc are observed and recorded5 Spontaneous venous pulsations - present or absent
Spontaneous venous pulsations are best seen by looking at the large veins on the disc
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Examination of Retinal Vessels
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Hypertensive Retinopathy
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Vascular Accidents
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Diabetic Retinopathy
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Systematic Viewing of the Fundus
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MacularFoveal Evaluation
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Management PlanAfter you have completed a careful recording of the clinical history of the patientrsquos complaints and a thorough examination of the eyes and their adnexa a working diagnosis should be achieved Additional laboratory or imaging studies may be required to confirm the clinical diagnosis Once the diagnosis has been made a proper treatment plan can be instituted
Dr Mazhry frcsfcps
Invistigations
bull FFA Fundus fluorescein angiographybull Perimetrybull Ultrasoundbull CTbull MRIbull Electrophysiological studies
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FFA
Dr Mazhry frcsfcps
CT scan
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Visual field
Indications Automated Perimetery
bull Diagnosis amp follow up of glaucoma
bull Diagnosis amp follow up of optic n diseases
bull Diagnosis amp follow up of retinal diseases
bull Neuro-ophthalmological disorders
Dr Mazhry frcsfcps
Ultrasound
bull Ultrasonographyndash Examination of post
Segment in opaquendash Mediandash Detection of IOFB (site
amp nature)ndash Diagnosis of orbital
diseases (Thyrotoxic)ndash Measurement of axial
length of the eye
Dr Mazhry frcsfcps
MRI
Dr Mazhry frcsfcps
Principles of Management
bull Treat the Symptomsbull Treat the Causebull Treat the Complications
ndash Of the diseasendash Of the treatment itself
Dr Mazhry frcsfcps
Guidelines for ocular referralsImmediate
ndash Non-traumatic red eyebull Acute glaucomabull Painful eye after cataract op
ndash Traumatic red eyebull Chemical burnbull Corneal lacerationbull Globe perforation
ndash Sudden visual lossbull Giant cell arteritisbull Retinal artery occlusion (if visual loss is less than 6 hrs)bull Any visual loss of less than 6 hrs cause
ndash Third nerve palsy with dilated pupil
Dr Mazhry frcsfcps
Guidelines for ocular referralsSame day
ndash Red eyebull iritisbull Corneal infection
ndash Traumabull Blunt traumabull Corneal abrasionbull Foreign body
ndash Swollen lidsbull Herpes zoster with ocular involvement ndash Hutchinsonrsquos signbull Orbital cellulitis
ndash Sudden visual lossbull Vitreous haemorrhagebull Sudden visual loss of more than 6 hrsbull Sudden onset floatersbull Retinal detachment
Dr Mazhry frcsfcps
Guidelines for ocular referrals
Same week or not at allbull Same week
ndash Persistent conjunctivitis
ndash Episcleritisndash Facial nerve palsy
bull Unless there is severe corneal exposure then within 24hrs
bull No referral neededbull Painless sticky eye of less than 24 hrsbull Chalazion
Dr Mazhry frcsfcps
Disc Quiz- Match with Correct labels
MCQ-1
MCQ-3
MCQ-2
MCQ-4
Normal Optic Disc
A Hypertensive PapillopathyB Disc swellingC Optic AtrophyD Glaucomatous Cupping