عامر يحيى رجب

Basic ophthalmology for medical studentsHistory and Examination

OCULAR HISTORY
1-Demographic data Name , Age , Sex ,Occupation and Nationality inherited disorders present at younger age while retinal vascular occlusion at old age X- linked color blindness and retinitis pigmentosa are common in males and most inflammatory conditions are common in females. Ocular diseases varies in geographical distribution(Behcet is common in middle-east). Primary open angle glaucoma is common in black. Patient occupation may affect ophthalmic treatment plan.

2- Chief complaint. with history of present illness. describing duration ,frequency, intermittency , onset rapidity location, severity ,associated symptoms and circumstances. pregnancy status , smoking and alcohol should be mentioned if related, pregnancy may have adverse effect on diabetic retinopathy and vascular lesions and good one on inflammatory conditions .smoking predispose predispose to vascular insults and aggravates thyroid ophthalmopathy.


3-Past ocular history . chronic ocular disease (glaucoma , refractive error ,amblyopia ,retinitis pigmentosa) surgical and laser procedures (cataract ,trab,PRPand refractive sx) ocular eye drops used (antiglaucoma) eye trauma ocular surgeries become difficult with history of previous surgeries and long time antiglaucoma eyedrops ,anterior uveitis and herpetic keratitis are usually recurrent, long life follow up is indicated for patient post trabeculectomy.
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4-Past medical history with major surgical history  DM ,HTN, CRF, IHD ,CVA,RA, SLE and other vascular problems. describing duration and severity. chronic infection TB ,Lyme ,HIV and syphilis  systemic diseases have great effect on the eye directly where the eye shows their manifestation (retinopathies) and complications (retinal vessel occlusion) or indirectly through their medication . Infection may present with uveitis and optic neuritis 
1
Diabetic retinopathy


5-Medications systemic meds used for chronic illness steroid –cataract , chloroquine ---maculopathy see=2 , ethbamutol --- optic neuropathy drugs may deposit in the cornea and lens ( amiodarone ---vertex keratopathy see =1) anticonvulsant may cause nystagmus .6-Ocular family history retinal dystrophies squint ,refractive errors, ,glaucoma and retinal detachment 7- Allergic history 2
2

Basic ocular examination

1- visual acuity determines the resolving power of the eye to see two different points as separate and usually tested by Snellen charts with decreasing sizes at fixed distance 6 meter and represented by ratio comparing the patient to normal values where the numerator indicates the test distance and the denominator indicates the lowest line seen. written by metric 6/6 ,6/9 ,---6/60 ,feet 20/20 ---20/200 or centile 1.0 ----0.1 . Patient with who failed to see the largest line may be approximated to the chart till they can see it (e.g. 3/60 means pt can see the largest letter at 3meters). Very poor vision can be tested by the ability to count fingers or seeing hand motion or light perception

60
36
24
18
12
9
6
VA = visual acuity CF= counting finger HM= hand motion LP= light perception NPL= no perception of light 6/6= 20/20=1 6/12 =20/40
Snellen chart


Pinhole test is useful detect people with poor vision caused by refractive errors (myopia , hyperopia and astigmatism ) by increasing the field of focus and decreasing most of defocused rays . Most refractive causes improve few lines while macular lesion may become worse
2- Field of vision gross field can be checked by ; finger counting in four quadrants confrontation testing by occlusion of each eye simultaneous confrontation testing with both eyes open and wiggling of the fingers Automated perimeter allows appropriate testing of field

Field defects

Humphrey visual field print out

3-Pupil examination

size miosis=small mydriasis=dilated equality unequal pupil size= anisocoria Shape may change due to post op ,trauma ,uveitis and coloboma Light reflex direct and indirect (consensual)weaker swinging light reflex (Marcus Gunn pupil=RAPD =consensual is more than direct) Light near dissociation = near response is greater than light reflex
Anisocoria in left Horner syndrome (see ptosis and miosis)
Posterior synechia Anterior uveitis
Iris coloboma
HOW TO TEST * dark room (to accentuate the reflex) * patient is looking at distant ( avoid accommodation) *pt should not look to the light source *use strong light

4- eye deviation and ocular motility

Check deviation by directing pen torch light to both eyes light image on temporal =esotropia light image on nasal = exotropia Ocular motility version = conjugate (same gaze) vergence =disconjugate (opposite direction) convergence and divergence Cover test for manifest squint (tropia) Cover&uncover test for latent squint (phoria) Commitant deviation = equal angle in all gaze Incommitant deviation ( paralytic) = deviation is more in the field of paralytic muscle. 6th nerve supplies lateral rectus muscle 4th nerve supplies superior oblique muscle 3rd nerve the remaining 4 muscles
Cardinal positions of gaze
Left hypotropia
Left esotropia
Left exotropia

5- external examination

A-Face skin lesion (zoster , hemangioma) deviation (Bell's palsy) Periorbital area for swelling ecchymosis and depositions B-Globe position -proptosis= forward enophthalmos =backward Globe size small (microphthalmos or nanophthalmos) large ( myopic ,buphthalmos)
Periorbital ecchymosis
Herpes zoster
Port wine stain (sturge weber syndrome R/O glaucoma)

Exophthalmos=proptosis

Buphthalmus = cong.glaucoma
Right microphthalmos
Left proptosis and inferior dystopia
Left enophthalmus

C-eyelid

position dropped (ptosis) retraction Lid defects colobomaLid skin lesion (blepharitis) Swelling ( cyst , chalazion)Lid ulceration (basal cell Ca)Eyelashes – loss hair ( madarosis) depigmented( poliosis) abnormal directed lashes (trichiasis) Lid margin turned in (entropion ) turned out (ectropion) Madarosis (blepharitis)
ptosis
poliosis
Basal cell Ca
entropion
ectropion
Lid retraction


Before you put pt in the slit lamp and while you are doing the previous exam have close look to the patient head ,globe and lid and observe any dynamic signs
-facial spasms or twitching Head nodding and head malposture Globe pulsation (carotid cavernous fistula) -Nystagmus -Jaw winking (ptotic lid retract with jaw movements) - Or you may see other signs


Jaw winking syndrome

6- slit lamp exam make the pt sits comfortably and you also

Use the minimum light and be systematic starting from the;Lid – skin and lid margin and eyelashes Conjunctiva- bulbar, fornix and tarsal ( with lid eversion)Cornea- with diffuse light and slit ( cross section) to see the( layers of the cornea epithelial defects, corneal opacities , filaments ,depositions ,keratic precipitates) Anterior chamber – depth , cells ,blood (hyphema)Iris- atrophy , nodules and rubeosisLens – status ( phakic ,aphakic or pseudophakic) opacity (cataract)position ( subluxated or dislocated )Anterior vitreous cells and opacities ptergium
Corneal abrasion
Iris nodules =uveitis
hyphema

Corneal precipitate =uveitis

Hypopyon=endophthalmitis
cataract
Lens subluxation


7- intraocular pressure (IOP)normal (10-22mmHg)tonometer= device measuring IOP different types*Goldman applanation tonometer (standard)fixed to slit lamp( needs topical anesthesia and fluorescein dye)*Tonopen ( electronic needs anesthesia)*air puff (noncontact)*Schiotz tonometr(indentation)
Goldman tonometer
Tonopen
Schiotz



8-funduscopy Retinal and optic disc exam need pupil dilatation Direct ophthalmoscope Uniocular ( no stereopsis) large image and small field and close to patient face Indirect ophthalmoscope Binocular(stereopsis= 3D)small image and large field need auxiliary lens (20D 28D) Slit lamp biomicroscopy Large image (fine retinal changes) with lenses(66D 78D 90)
Indirect ophthalmoscope
Retinal detachment
papilloedema
Direct ophthalmoscope


Fluorescein dye :it is yellow in color but fluorescences green with blue light commonly used FOR: -detect epithelial defects in the cornea and conjunctiva - with Goldman tonometry  - detect ocular wounds leakage (Siedle test) - contact lens fitting - detect patency of the lacrimal passages- intravenous fluorescein used to study retinal and choroidal vesselsit is available as drops or strips or IV solution

Pupil dilatation (mydryasis)commonly used to - examine mid and peripheral retina - before cataract surgery to facilitate lens extraction and avoid iris damage. - with uveitis to prevent synechia Most common mydriatic drops Tropicamide (mydriacyl) mydriatic and weak cycloplegic 0.5%and 1% lasts 6hours cylcopentolate (cyclogyl) 0.5%and 1% cycloplegic and mydriatic lasts 24 hours Atropine 0.5% and 1% mydriatic and cyloplegic lasts up to 2weeks ( all the above are parasympatholytic ) Phenylephrine 2.5% only mydriatic lasts 4hours ( sympathomemitic )

Adjunctive examinations

-Lid eversion look for subtarsal FB -Fluorescein staining of corneal epithelial defect -Gonioscopy =viewing anterior chamber angle structures -Prism s used for measuring eye deviation pre operatively -ruler used for evaluation of ptosis -Hertel exophthalometer for measuring proptosis -Color vision by Ishihara plates -Automated perimetry ( Humphrey and Octopus) for visual field

-Keratometer for corneal curvature(power) -Topography for corneal surface mapping -A scan US for axial length measure -B scan US for retinal detachment and vitreous hemorrhage in opaque media Optical coherent tomography Schirmer test for quantity in dry eye (Sjogren syndrome) -Biometry = IOL calculation (need axial length and keratometer) - Optic nerve analyzer for glaucomatous damage

CORNEAL TOPOGRAPHY

Gonogioscopy
OCT
B scan US


Postnatal period Fixation starts developing in first month and is completed in 6 months. Macula is fully developed by 4-6 months. Fusional reflexes, stereopsis and accommodation is well developed by 4-6 months. Cornea attains normal adult diameter by 2 years of age. Lens grows throughout life

Common ocular signs and symptoms terminology

Photopsia= seeing flashes of light Photophobia= abnormal sensitivity to light Epiphora= overflow of tears due to defective drainage Metamorphopsia= distorted images Floaters= flying and moving lines and dots Micropsia= small images Macropsia= large images Halos= circles around light sources Scotoma= defect in the field of vision Dyschromatopsia= disturbed color vision Nyctalopia= night blindness Diplopia= double vision Anopia = loss vision in one eye Hemianopia= half visual field defect for both eyes Glare= visual defect infront of light source Amourosis fugax= uniocular transient loss of vision Cotton wools= infarcted retinal nerve fibers Papilloedema= bilateral disc swelling due to raised intracranial pressure Anisocoria=unequal pupils Heterochromia iridis= different colored irises Microphthalmia= small disorganized eye Nanophthalmia or macrophthalmia= normal small or large globe Aniridia= absence of iris Blepharitis = inflammation of eyelids Buphthalmus= large globe in pediatric glaucoma Hypotony = low intraocular pressure Keratoconus = cone shaped cornea

Proptosis( exophthalmos)= forward globe displacement Ptosis= dropping of the upper eyelid Enophthalmos= backward globe displacement Trichiasis= inward directed eyelashes Ectropion =outward directed lid margin Entopion= inward directed lid margin Lagophthalmos= incomplete lid closure Lid lag = decrease lid descent on down gaze Lid retraction = elevated lid Nebula ,macula and leukoma= grades of corneal opacity Vogt stria= stretch lines on descemet membrane Descematocele= exposed descemet membrane Keratic precipitate= inflammatory cells on the corneal endothelium Hypopyon= pus in the anterior chamber Hyphema = blood in the anterior chamber Anterior and posterior synechia= adhesion of the iris with the cornea and the lens(respectively) Aphakia =no lens Pseudophakia= artificial intraocular lens Rubeosis= iris neovascularization Poliosis= depigmented eyelashes Madarosis= loss of eyelashes Staphyloma= protruded thinned part of the eyeball Symblepharon= adhesions between bulbar and lid conjunctiva Tropia =squint =strabismus Exotropia=divergent squint esotropia= convergent squint Pannus = abnormal blood vessels invading the cornea