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The Ocular Examination

Karla J. Johns, M.D.

The Ocular Examination

The Ocular Review of Systems

Ocular Review of Systems

Decreased vision
Severity Onset Permanence

Ocular Review of Systems

Diplopia
monocular vs. binocular horizontal vs. vertical

Ocular Review of Systems

Ocular Discomfort
Itching & burning Asthenopia Photophobia Severe pain

Ocular Review of Systems

Other ocular symptoms


Floaters

Ocular Review of Systems

Other ocular symptoms


Flashing lights

Ocular Review of Symptoms

Other ocular symptoms


Visual field defects

Ocular Medication History


Be sure to ask about eye drops Many topical medications (eye drops) have systemic effects

The Ocular Examination


Visual acuity Pupils Motility Visual fields External eye & anterior segment inspection Red reflex and retinal examination

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

V = visual acuity N = near visual acuity


OD = right eye OS = left eye OU = both eyes together cc = with glasses sc = without glasses PH = vision through a pinhole

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 Through a Pinhole

Visual Acuity

OD 20/60 Pinhole 20/30 OS 20/60 Pinhole no change

Visual Acuity

Assessing the visually impaired patient


If unable to see the largest letter on the chart, move patient closer to the eye chart (Change the numerator of the Snellen fraction)

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

Near visual acuity is a common bedside test


Patient to wear reading glasses, if any Test at 14 inches, one eye at a time Recorded as Snellen equiv. or Jaeger point size (J)

Recording Near Visual Acuity

N N

OD 20/40 OS 20/20 -or-

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

Pupillary Light Reflexes

Pupils

Test pupillary light reactions


Direct Consensual

Pupils

Test for afferent pupillary defect (RAPD, or Marcus Gunn pupil) with swinging flashlight test

Swinging Flashlight Test

Normal findings: the pupils both constrict when you swing the flashlight

Swinging Flashlight Test

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

Swinging Flashlight Test

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

Test for accommodative (near) reflex

Pupils

Summary of pupil exam


Inspection Direct & Consensual light reaction Swinging flashlight for RAPD Accommodative response

Motility examination

Motility examination

A part of both the ocular exam and the neurologic examination

Motility examination
EOMs ennervated by cranial nerves III, IV and VI

Motility examination

Corneal light reflex

Motility examination

Examples of strabismus seen with abnormal corneal light reflexes

Motility examination

Types of strabismus

Motility examination

Assess extraocular movements


(Look for smooth conjugate movements in all fields of gaze)

Motility examination

Examples of abnormalities of extraocular movements

Left eye cannot abduct

Restricted upgaze of left eye

Ocular Motility

Summary of ocular motility assessment


Corneal light reflexes Assessment of extraocular movements

Ocular Motility

An additional test
Cover-uncover test

Visual Fields

Part of both the ocular examination and the neurologic examination

Visual Fields

Confrontation visual field testing


You should be at eye level with the seated patient, 2 3 feet away Patient occludes one eye Ask the patient to look at your eye Close your left eye to test the patients right eye, and close your right eye to test the patients left eye Present your fingers as a target, half-way between yourself & the patient, and ask the patient when they come into view

Confrontation visual field testing

Visual Fields

Visual Fields

Recording abnormalities of the visual fields

Normal

Bitemporal hemianopsia

Visual loss in right eye

Inspection of the External Eye and the Anterior segment

Inspection of the External Eye and Anterior Segment


1.
2. 3.

4.
5. 6.

Eyelids Conjunctiva & Sclera Cornea Anterior chamber Iris Lens

Inspection of the External Eye and Anterior Segment

Other Diagnostic Tests


Fluorescein dye to stain corneal abrasions
Corneal abrasion stained with fluorescein Instilling fluorescein strip

Inspection of the External Eye and Anterior Segment

Other diagnostic techniques

Eversion of the upper lid to find foreign body

Grasp lashes and place Q-tip 1 cm from lid margin

Flip eyelid margin over Q-tip

Inspection of the External Eye and Anterior Segment Other diagnostic techniques
Eversion of the upper eyelid to find foreign body

Red Reflex and Retinal Examination

Direct Ophthalmoscope
Provides a monocular 15X view of the retina Parts of the ophthalmoscope:

Viewing aperture Focus wheel Aperture wheel

The Focus Wheel


Plus lenses (black or green numbers) that correct hyperopia (farsightedness) Minus lenses (red ) that correct myopia (near-sightedness) Plano = no lens The lenses can correct the refractive error of the patient, the doctor, or both

The Aperture Wheel


The apertures vary according to the type of ophthalmoscope; most are rarely used The small round white light is most useful for small pupils, and the large round white light for large pupils

Direct Ophthalmoscope
Rule

Number One:

If a bright light shines in

your eye, youre holding it the


wrong way !

Direct Ophthalmoscope

Assessing the red reflex


Focus wheel at +6 Look straight at patients eye from about 12 inches Focus the sharpness of the red reflex

(Your textbook advises focus wheel at 0 and distance from patient = 15 inches; thats okay, too, but my way is easier !)

Direct Ophthalmoscope

The Normal Red Reflex

Examples of abnormal red reflex

Direct Ophthalmoscope

Cataract (lens opacity)

Intraocular Tumor

Direct Ophthalmoscope

Technique for retinal examination


Darken the room Have patient look straight ahead Examine patients right eye with your right eye, and left eye with left Rest your thumb on the patients brow to aid your proprioception

Direct Ophthalmoscope

Technique for retinal examination


Align yourself about 15 degrees temporal to the patients line of sight Slowly approach the patient, keeping the pupil in view, moving the focus wheel closer to zero When you are very close to the patient, the retina will come into focus

Direct Ophthalmoscope

Technique for retinal examination

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

Good dilating drops to use:


Neosynephrine 2.5 % (phenyleprine) Mydriacyl .5% or 1 % (tropicamide) Dont use Atropine or Neosyneprine 10%

Direct Ophthalmoscope:

Patient is neurologically unstable

Contraindications to dilating the pupil

Patient may have an open eye injury

Direct Ophthalmoscope

Contraindications to dilating the pupil


The patient has a shallow anterior chamber (Risk of the iris blocking the flow of aqueous and causing acute pressure rise)

(This is rare; usually in elderly patients)

Direct Ophthalmoscope

The tangential flashlight test to rule out a narrow anterior chamber

Direct Ophthalmoscope

Technique for retinal examination


When a vessel comes into view, follow a bifurcation as it points you toward the optic disc When the disc comes into view, adjust your focus

Direct Ophthalmoscope

Systematic examination of the retina


Optic disc Retinal vessels Retinal background Macula

Direct Ophthalmoscope

Field of view is smaller than textbook photographs

Field of view: Direct Ophthalmoscope

Field of view: Fundus photograph

Optic Disc Assessment


Sharpness of the disc margin
Normal nasal margin may be slightly blurry

Color of the disc


Normal is orange or pinkish

Contour of the disc


Should be flat with central cup

Optic Disc Assessment

Pigment crescents and white scleral crescents are normal variants

Optic Disc Assessment


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

Normal flat disc

Swollen disc

Optic Disc Assessment

Optic cup should be half the width of the disc (CD ratio) A large CD ratio is suggestive of glaucoma

Optic Disc Assessment

When describing lesions or distances, the optic disc diameter (DD) is a convenient ruler

Pigmented lesion 1 DD from the disc

The optic disc is about 1.5 mm in diameter

Retinal vessel assessment

From the disc, follow each arcade of vessels (a paired artery & vein) peripherally Look for smooth, gradual tapering

Distinguishing arteries & veins Arteries Veins


Bright red Narrower Bright light reflex

Retinal Vessel Assessment:


Darker red Wider Inconspicuous or absent light reflex

Retinal Vessel Assessment

Abnormal vessel caliber changes: arteriovenous crossing changes


Knick

A-V Nicking

A-V Banking

Example of A-V banking & nicking

Assessment of retinal background

Normal variation of retinal background pigmentation

Assessment of retinal background

View retinal background to make sure there are no hemorrhages, exudates, or other abnormalities

Abnormal retinal background with hemorrhages & exudates

Assessment of the macula


Two ways to find the macula
1.

2.

Direct the ophthalmoscope 2 disc diameters temporal to the disc, or, Ask the patient to look at the light

Assessment of the macula

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

Systematic evaluation of the retina


Optic disc Retinal blood vessels Retinal background Macula

The Ocular Examination


Visual acuity Pupils Motility Visual Fields Inspection of the external eye and anterior segment Red reflex and retinal examination

The Ocular Examination


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

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