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Decreased vision
Severity Onset Permanence
Diplopia
monocular vs. binocular horizontal vs. vertical
Ocular Discomfort
Itching & burning Asthenopia Photophobia Severe pain
Visual Acuity
Visual Acuity
20/20
The Snellen Fraction
Numerator: testing distance (20 ft) Denominator: distance at which a normal eye can read the line of letters
Visual Acuity
Testing protocol
Patient 20 feet from eye chart Chart well illuminated Distance glasses, if any, should be worn Cover non-tested eye completely Record the line of letters of which the patient can identify more than half
Visual acuity
Standard abbreviations
Visual Acuity
OD 20/20 1 OS 20/30 + 2
Visual Acuity
If patient cannot read the 20/20 line, measure visual acuity through a pinhole to determine the potential vision of the eye Useful in emergency settings
Visual Acuity
Visual Acuity
OD 10/200 OS 5/200
Visual Acuity
Assessing the visually impaired patient HM = Hand Motion CF = Count Fingers LP = Light Perception NLP = No Light Perception
Visual Acuity
N N
OD J2 OS J1
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
Pupils
Pupils
Pupils
Test for afferent pupillary defect (RAPD, or Marcus Gunn pupil) with swinging flashlight test
Normal findings: the pupils both constrict when you swing the flashlight
Abnormal Finding: the pupils dilate when you swing the flashlight into one of the eyes, but constrict when you swing the flashlight into the other pupil
A relative afferent pupillary defect (RAPD), also known as a Marcus Gunn pupil, is a clinical sign of an optic nerve or diffuse retinal lesion Please remember this forever
Pupils
Pupils
Motility examination
Motility examination
Motility examination
EOMs ennervated by cranial nerves III, IV and VI
Motility examination
Motility examination
Motility examination
Types of strabismus
Motility examination
Motility examination
Ocular Motility
Ocular Motility
An additional test
Cover-uncover test
Visual Fields
Visual Fields
Visual Fields
Visual Fields
Normal
Bitemporal hemianopsia
4.
5. 6.
Inspection of the External Eye and Anterior Segment Other diagnostic techniques
Eversion of the upper eyelid to find foreign body
Direct Ophthalmoscope
Provides a monocular 15X view of the retina Parts of the ophthalmoscope:
Direct Ophthalmoscope
Rule
Number One:
Direct Ophthalmoscope
(Your textbook advises focus wheel at 0 and distance from patient = 15 inches; thats okay, too, but my way is easier !)
Direct Ophthalmoscope
Direct Ophthalmoscope
Intraocular Tumor
Direct Ophthalmoscope
Direct Ophthalmoscope
Direct Ophthalmoscope
Panoptic Ophthalmoscope
Panoptic Ophthalmoscope
Direct Ophthalmoscope
Dilating drops make the retinal examination much easier Dilating drops are not routinely used by non-ophthalmologists but may be used in specific circumstances
Direct Ophthalmoscope
Direct Ophthalmoscope:
Direct Ophthalmoscope
Direct Ophthalmoscope
Direct Ophthalmoscope
Direct Ophthalmoscope
Direct Ophthalmoscope
Optic disc should be flat Elevation of the disc is seen more easily in vivo than in photographs Bilateral optic disc swelling from increased intracranial pressure is papilledema
Swollen disc
Optic cup should be half the width of the disc (CD ratio) A large CD ratio is suggestive of glaucoma
When describing lesions or distances, the optic disc diameter (DD) is a convenient ruler
From the disc, follow each arcade of vessels (a paired artery & vein) peripherally Look for smooth, gradual tapering
A-V Nicking
A-V Banking
View retinal background to make sure there are no hemorrhages, exudates, or other abnormalities
2.
Direct the ophthalmoscope 2 disc diameters temporal to the disc, or, Ask the patient to look at the light
Darker in color than the surrounding retina Retinal vessels do not extend into the central macula Often a shiny central foveal reflex is seen
Direct Ophthalmoscope
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 segment abnormalities, and tutorial session at Vanderbilt Eye Institute