Junior Intern Review

Carlo Galang, MD
REMINDERS
  CHILL tfo
  Med Bag
  WORKING penlight
  Millimeter ruler
  Jaeger (near vision) chart
  Occluder with pinhole
  Books
  Post-its/markers on pages
  Notebook
  PRAY
  General data
  Name, age, sex, occupation
  Chief complaint
  Blurring of vision, redness, eye discomfort
  History of Present Illness
  When did it start? Sudden or gradual? Character? Precipitating/
alleviating factors?
  Past Medical History
  Hypertension, DM, PTB, thyroid disease, allergy, glaucoma,
autoimmune disease,
  Visual Acuity
  External Eye Exam, EOMs
  Fundoscopy
DISTANCE
  SC= without
NEAR
correction
  SC= without correction
  PH= pinhole   CC= with correction
  CC= with correction
 20/63

Visual Acuity

20/200

20/160
20/125
20/100
20/80
20/63

20/20

Always make sure the other eye not being tested is covered!
 20/20

Visual Acuity

20/200

20/160
20/125
20/100
20/80
20/63

20/20
Amsler Grid
  Central 20 degrees of visual field
  Normal reading distance
  Corrected visual acuity for near – READING GLASSES
External Eye Exam
  Lids – swelling, masses, ptosis?
  Lashes – misdirected, extra rows, matting?
  Conjunctiva – hyperemic?
  Sclera – icteric?
  Cornea – clear? Hazy?
  Anterior chamber – deep?
  Iris – pigmented? Rubeosis?
  Pupils – Size? Equal? Reactive to Light? RAPD?
  Lens – clear? Slightly opaque?
Common Ocular Symptoms
  Abnormalities of vision
  Blurring of vision
  Double vision

  Abnormalities of ocular appearance

  Redness
  Fleshy mass on the cornea
  Lesions on the eyelids; discharge

  Abnormalities of ocular sensation

  Pain
  Discomfort; itching; dryness
  Foreign body
ERRORS OF REFRACTION

  Myopia

  Hyperopia

  Astigmatism

  Presbyopia
Pinhole Acuity Test
  Pinhole admits only central rays of light, which do not
require refraction by cornea or lens
  If acuity improves by 2 or more lines, patient likely has EOR
  If acuity DOES NOT improve, patient may have non-
refractive causes for the reduced VA
Causes of Refractive Errors
  Eye length

  Corneal curvature

  Lens curvature
Myopia
  Image of distant objects focuses in front of the retina.

  Eye is longer than the average (Axial Myopia)

  Refractive elements have more refraction than average

(Curvature/Refractive Myopia)
Hyperopia
  Image is focused behind the retina.

  Eye is shorter than average (Axial Hyperopia)

  Refractive elements have less power (Refractive Hyperopia)

Astigmatism
  Eye produces an image with multiple focal points/lines
Refractive States of the Eye
  Emmetropia
  Ametropia
  Myopia (nearsighted)
  Hyperopia (farsighted)
  Astigmatism
Presbyopia
  Accomodation – eye changes refractive power by altering the
shape of its crystalline lens.

  Loss of accommodative ability of crystalline lens

Management
  Use of lenses to achiever the best possible acuity on distance
and near vision tests.
  Subjective
  Objective = retinoscopy
  Prisms (technically not lenses)
  Wedge of refracting material with triangular cross section,
deviates light toward its base.
  Image displaced toward the apex.
  Spherical lenses can be thought of as paired prisms
Convergent (+) – base to base
Divergent (-) – apex to apex
Prism Diopters (PD) – deviates parallel rays of light 1 cm
when measured at a distance of 1m from prism.
PD = 1cm/deviating distance(m)
Types of Lenses
  Spheres
  Same curvature over its entire surface, same power in all
meridians
  CONVE(x) = CONVErge = plus (+)
  1 diopter plus power converges parallel rays of light to focus at
1m from the lens.
  Concave = diverge = minus (-)
  Parallel light rays enter the lens appear to diverge
  Virtual image is considered to appear at a focal point in front of
the lens
conveX conCAVE
  Cylindrical
  Vergence power in only one meridian
  Power is perpendicular to the axis of meridian
  Focuses light rays to a line

  Spherocylindrical
  Focuses light in two line foci
  Shape of light rays = conoid of Sturm
  Between the two-line foci = circle of least confusion (best
over-all focus for a spherocylindrical lens)
Case: 19/M
  CC: blurring of vision, OU
  HPI: difficulty reading at far, “fuzzy”. Noticed during class,
difficulty seeing words written on the board/powerpoint.
  PE:
  VA:

OD OS
SC 20/100 | J1 20/125 | J1
PH 20/30 -2 20/40 +2
CC No corrective lenses No corrective lenses

  Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, lens,

EOMs
  Fundoscopy: +ROR, clear media, distinct disc margins, AV 2:3,
CD 0.3
CATARACT
  Any opacity in the lens
  Aggregation or denaturation of lens proteins
  From oxidative damage, ultraviolet light

  Mature – all lens protein are opaque

  Immature – has some transparent protein

  Hypermature – cortical proteins have become liquid

  Morgagnian – lens nucleus floats in the capsular bag

Causes; symptoms
  A – Aging
  Nuclear sclerosis
  May have improved near vision w/o glasses (second sight)
  Monocular diplopia
  B – Blow out (TRAUMA)
  Foreign body to the lens; blunt trauma (star-shaped)
  C – Congenital – Pedia (remove part of the PC)
  Rubella, disorders of metabolism
  D – Diabetes, drugs
  Cortical
  Corticosteroids, phenothiazines

After-cataract – opacification of posterior capsule (proliferating

epithelium)
Significant problem in almost all pedia patients
Treatment
  Surgery
  Phacoemulsification
  Extracapsular Cataract Extraction
  Intracapsular Cataract Extraction
  Mechanical irrigation/aspiration handpiece
Case: 64/F
  CC: blurring of vision, OU
  HPI: 3 years progressive worsening of vision, “cloudy”. +glare
when seeing car headlights.
  PE:
  VA:

OD OS
SC 20/100 | J8 20/125 | J8
PH 20/50 -2 20/63 +2
CC J1 J1

  Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, LENS,

EOMs
  Fundoscopy: +faint ROR, slightly hazy media, distinct disc
margins, AV 2:3, CD 0.3
DRY EYE SYNDROME
  Tears
  7-19 um thick, covers corneal and conjunctival epithelium.
  Wet and protect surface of cornea
  Inhibit growth of microorganisms, antimicrobial enzymes
  Contains IgA, IgG, IgE
  Corneal nutrition, K, Na, Cl

  Causes
  Hypofunction of lacrimal gland Sjogren’s, Irridation, Mumps
  Mucin deficiency – SJS, chemical burns, anti-muscarinics
  Lipid deficiency – lid margin scarring, blepharitis
  Defective spreading of Tear Film – pterygium, decreased blinking
Monomolecular film of lipid
from Meibomian glands.

Retards evaporation

From major and minor

lacrimal glands.

Contains salts and proteins

Glycoprotein, overlies
cornea and conjunctiva.

Epithelial cells composed of

lipoprotein – mucin partly
absorbed; anchored by
microvilli
Symptoms; Signs
  Itchy, sandy, foreign body sensation
  Redness, stinging sensation, pain

  Absent tear meniscus

  Tear Break-up Time
  Dry spots
  >10 seconds = Normal
Treatment
  Artificial tears
  Carboxymethylcellulose 1gtt 4-6x/day
  Hypromellose
  Sodium hyaluronate
  Preservative-free artificial tears
  Ointment/eye gel
  TID or ODHS
  May cause blurring of vision
  Blepharitis – lid hygiene and topical antibiotics
  Severe – punctal plugs, electrocautery.
Case: 24/F
  CC: foreign body sensation
  HPI: 3 months foreign body sensation, noticed when watching
television or when patient is reading. Occasional redness,
itchiness.
  PE:
  VA:
OD OS
SC 20/20| J1 20/20| J1
PH 20/20 20/20
CC No corrective lenses No corrective lenses

  Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, lens,

EOMs
  Fundoscopy: +ROR, clear media, distinct disc margins, AV 2:3,
CD 0.3
CONJUNCTIVITIS

  Viral

  Bacterial

  Allergic
  Visual Acuity
  Distance
  Near
  Amsler

  Slit-Lamp Examination

  Red/Pink Eye
  What do we rule out?
Signs/Symptoms
  Pruritus, discharge, redness, foreign body sensation, fullness
around the eyes, pain – cornea may be affected

  Hyperemia, lacrimation, papillary hypertrophy

  Edema of conjunctival stroma
  Hypertrophy of lymphoid layer of stroma
Viral
  Most common – usually caused by adenovirus (after URTI)

  Watery tearing, occasionally mucous discharge.

  Follicles on palpebral conjunctiva

  Preauricular lymph nodes, submandibular lymph nodes

Bacterial
  Mucopurulent discharge

  Matting of eyelashes, difficulty opening eyes in the morning,

crusts on eyelashes

  Papillae on palpebral conjunctiva

  Staph, Strep, Haemophilus, Chlamydial, Gonoccocal

Allergic
  Red/pinkish eyes, follicles

  Watery discharge, chemosis

  History: allergic rhinitis, asthma

Management
  Viral
  Supportive
  Antibiotic drops

  Bacterial
  Fluoroquinolones
  Aminoglycosides
  1 drop 4-6 times daily
  Frequent hand hygiene

  Allergic
  Antihistamines
  Cold compress
Case: 36/M
  CC: eye redness and discharge
  HPI: 3 days history of eye redness, with whitish-yellowish
discharge. Difficulty opening eyes due to matting of eyelashes. No
photophobia.
  PE:
  VA:
OD OS
SC 20/50 | J1 20/30 | J1
PH 20/20 20/20
CC No corrective lenses No corrective lenses

  Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, lens,

EOMs
  Fundoscopy: +ROR, clear media, distinct disc margins, AV 2:3,
CD 0.3
SUBCONJUNCTIVAL HEMORRHAGE
  Bleeding under the conjunctiva
  Generally benign

-  Spontaneous
-  Coughing, sneezing, bending over, vomiting, valsalva
maneuver, lifting heavy objects
-  Trauma or surgery
-  Recurrent arteriosclerosis (elderly)
-  Impaired coagulation (hemophilia, aspirin)
Treatment
  Assurance
  Supportive
  Artificial tears
  Cold compress then warm after.
PTERYGIUM vs. PINGUECULA
  Pterygium
  Wing-shaped, triangular growth of tissue that extends from
the conjunctiva the cornea, usually on the nasal side
  Fibrovascular; almost always preceded by pinguecula
  Pigmented iron line at the anterior edge of the pterygium
(Stocker line)
  Pinguecula
  Same, but NOT reaching the cornea.
  Yellowish nodule temporal/nasal to the cornea
  Symptoms/Signs
  Pugita (pterygium), foreign body sensation, redness, itching,
tearing
  Cause: Sun, Sand, Wind
  Elastotic degeneration (actinic damage from UV)
  Treatment:
  Pterygium: excision with conjunctival autograft – reduces
recurrence rate to 6-5% (vs. 24-89% - bare sclera); alternative
amniotic membrane graft
  Pinguecula: lubricants, weak steroids (pingueculitis)
Case: 35/M
  CC: eye redness and yellow-whitish bumps on the nasal side of the
conjunctiva
  HPI: 1 week history of eye redness, spontaneously resolves, no
discharge. Foreign body sensation.
  PE:
  VA:
OD OS
SC 20/20 | J1 20/20 | J1
PH
CC No corrective lenses No corrective lenses

  Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, lens,

EOMs
  Fundoscopy: +ROR, clear media, distinct disc margins, AV 2:3,
CD 0.3
HORDEOLUM
EXTERNAL vs. INTERNAL
  Infection of Zeis and Moll (Stye)
  Infection of Meibomian gland

  Symptoms: pain, erythema, swelling

  Causes:
  Staph infection
  Treatment:
  Warm compress 10-15 mins, TID-QID
  If no resolution in 48 hours – I&D
  Internal – vertical incision
  External – horizontal incision
  Antibiotics – ointment; oral; Co-amox BID if with preseptal cellulitis
CHALAZION
  Idiopathic, sterile, chronic granulomatous inflammation of
meibomian gland
  Painless swelling
  Biopsy indicated for recurrent chalazion; meibomian gland
carcinoma mimics the appearance of chalazion
  I&C; vertical incision (conjunctival surface), horizontal (skin
surface)
Visual Acuity
angular measurement of testing distance to the minimal object size
resolvable at that distance
Vital sign of the eyes

20 – testing distance
50 – distance at which a normal/unimpaired eye can see that
line

Near vision – Jaeger notation

Test Targets
  Optotypes – individual letter/number or picture on a testing
chart
  B – hardest for patients to recognize, misinterpreted as E or 8
  C, D, O
  L – easiest
References/Sources
  http://www.visionaware.org/info/your-eye-condition/guide-to-
eye-conditions/refractive-error-and-astigmatism/125

  http://www.allaboutvision.com/eye-exam/refraction.htm

  American Academy of Ophthalmology

  Kanski

  Vaughan and Asburys

GOODLUCK!