eye exam i
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The
OcularExamination
Karla J. Johns, M.D.
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The Ocular Examination
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The Ocular
Review of Systems
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Ocular Review of Systems
Decreased vision
Severity
Onset Permanence
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Ocular Review of Systems
Diplopia
monocular vs. binocular
horizontal vs. vertical
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Ocular Review of Systems
Ocular Discomfort
Itching & burning
Asthenopia Photophobia
Severe pain
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Ocular Review of Systems
Other ocular symptoms
Floaters
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Ocular Review of Systems
Other ocular symptoms
Flashing lights
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Ocular Review of Symptoms
Other ocular symptoms
Visual field defects
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Ocular Medication History
Be sure to ask about eye drops
Many topical medications (eye
drops) have systemic effects
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The Ocular Examination
Visual acuity
Pupils
Motility Visual fields
External eye & anterior segment
inspection Red reflex and retinal examination
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Visual Acuity
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Visual Acuity
20/20The Snellen Fraction
Numerator: testing distance (20 ft) Denominator: distance at which a
normal eye can read the line of letters
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Visual Acuity
Testing protocol
Patient 20 feet from eye chart
Chart well illuminated
Distance glasses, if any,should be worn
Cover non-tested eyecompletely
Record the line of letters ofwhich the patient canidentify more than half
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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
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Visual Acuity
OD 20/20 1OS 20/30 + 2V
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Visual Acuity If patient cannot read
the 20/20 line, measurevisual acuity through apinholeto determine
the potential vision ofthe eye
Useful in emergencysettings
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Visual Acuity Through a
Pinhole
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Visual Acuity
OD 20/60 Pinhole 20/30
OS 20/60 Pinhole no changeV
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Visual Acuity
Assessing the visually impairedpatient
If unable to see the largest letter onthe chart, move patient closer to theeye chart (Change the numerator ofthe Snellen fraction)
OD 10/200OS 5/200V
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Visual Acuity
Assessing the visuallyimpaired patient
HM = Hand Motion
CF = Count Fingers
LP = Light Perception
NLP = No Light Perception
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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)
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Recording Near Visual Acuity
OD 20/40
OS 20/20
-or-
OD J2OS J1
N
N
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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
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Pupils
Pupillary Light Reflexes
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Pupils Test pupillary light reactions
Direct
Consensual
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Pupils Test for afferent pupillary defect
(RAPD, or Marcus Gunn pupil)with swinging flashlight test
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Swinging Flashlight Test
Normal findings: the pupils bothconstrict when you swing the flashlight
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Swinging Flashlight Test Abnormal Finding: thepupilsdilate
when you swing the flashlight into oneof the eyes, but constrictwhen youswing the flashlight into the other pupil
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Swinging Flashlight Test
A relative afferent pupillary defect(RAPD), also known as a MarcusGunn pupil, is a clinical sign of anoptic nerve or diffuse retinal lesion
Please remember this forever
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Pupils
Test for accommodative (near)reflex
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Pupils
Summary of pupil exam
Inspection
Direct & Consensual light reaction
Swinging flashlight for RAPD
Accommodative response
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Motility examination
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Motility examination
A part of both the ocular exam andthe neurologic examination
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Motility examinationEOMs ennervated by cranial nerves III, IV
and VI
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Motility examination
Corneal light reflex
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Motility examination Examples of strabismus seen with
abnormal corneal light reflexes
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Motility examination Types of strabismus
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Motility examination Assess extraocular movements
(Look for smooth conjugate movements in allfields of gaze)
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Motility examination Examples of abnormalities of
extraocular movements
Left eye cannotabduct Restricted upgaze of left eye
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Ocular Motility
Summary of ocular motilityassessment
Corneal light reflexes
Assessment of extraocularmovements
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Ocular Motility
An additional test
Cover-uncover test
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Visual Fields Part of both the ocular examination
and the neurologic examination
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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 righteye, and close your right eye to test thepatients left eye
Present your fingers as a target, half-waybetween yourself & the patient, and ask thepatient when they come into view
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Visual Fields Confrontation visual field testing
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Visual Fields
Recording abnormalities of thevisual fields
Normal Bitemporal hemianopsia Visual loss
in right eye
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Inspection of the External Eye
and the Anterior segment
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Inspection of the External Eye
and Anterior Segment1. Eyelids
2. Conjunctiva & Sclera
3. Cornea4. Anterior chamber
5. Iris
6. Lens
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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
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Inspection of the External Eye andAnterior Segment
Other diagnostic techniques
Eversion of the upper eyelid to findforeign body
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Red Reflex and Retinal
Examination
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Direct Ophthalmoscope
Provides a monocular 15X view ofthe retina
Parts of the
ophthalmoscope:
Viewing aperture
Focus wheel
Aperture wheel
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The Focus Wheel
Plus lenses (blackor greennumbers)that correct hyperopia (far-sightedness)
Minus lenses (red) that correctmyopia (near-sightedness)
Plano = no lens
The lenses can correct the refractiveerror of the patient, the doctor, orboth
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The Aperture Wheel
The apertures vary according tothe type of ophthalmoscope; mostare rarely used
The small round white light ismost useful for small pupils, andthe large round white light for
large pupils
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Direct Ophthalmoscope
The Normal Red Reflex
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Direct Ophthalmoscope Examples of abnormal red reflex
Cataract (lens opacity) Intraocular Tumor
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Direct Ophthalmoscope
Technique for retinal examination
Darken the room
Have patient look straight ahead
Examine patients right eye with yourright eye, and left eye with left
Rest your thumb on the patients
brow to aid your proprioception
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Direct Ophthalmoscope
Technique for retinal examination Align yourself about 15 degrees
temporal to the patients line of sight
Slowly approach the patient, keepingthe pupil in view, moving the focuswheel closer to zero
When you are very close to the
patient, the retina will come intofocus
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Direct Ophthalmoscope
Technique for retinal examination
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Panoptic Ophthalmoscope
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Panoptic Ophthalmoscope
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Direct Ophthalmoscope
Dilating drops make the retinalexamination much easier
Dilating drops are not routinelyused by non-ophthalmologists butmay be used in specificcircumstances
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Direct Ophthalmoscope
Good dilating drops to use:
Neosynephrine 2.5 % (phenyleprine)
Mydriacyl .5% or 1 % (tropicamide)
Dont use Atropine or Neosyneprine10%
Direct Ophthalmoscope:
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Direct Ophthalmoscope:Contraindications to dilating the
pupil Patient isneurologicallyunstable
Patient may have anopen eye injury
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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)
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Direct Ophthalmoscope
The tangential flashlight test torule out a narrow anterior chamber
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Direct Ophthalmoscope
Technique for retinalexamination
When a vessel comes intoview, follow a bifurcationas it points you toward theoptic disc
When the disc comes intoview, adjust your focus
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Direct Ophthalmoscope
Systematic examination of the retina
Optic disc
Retinal vessels
Retinal background Macula
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Direct Ophthalmoscope
Field of view is smaller thantextbook photographs
Field of view:
Direct Ophthalmoscope
Field of view:
Fundus photograph
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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
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Optic Disc Assessment
Pigment crescents and white scleralcrescents are normal variants
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Optic Disc Assessment
Optic disc should be flat
Elevation of the disc isseen more easily in vivo
than in photographs Bilateral optic disc
swelling from increased
intracranial pressure ispapilledema
Normal flat disc
Swollen disc
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Optic Disc Assessment
Optic cup should behalf the width of thedisc (CD ratio)
A large CD ratio issuggestive ofglaucoma
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Optic Disc Assessment
When describinglesions ordistances, the
optic discdiameter (DD) is aconvenient
ruler
Pigmented lesion 1 DDfrom the disc
The optic disc is about 1.5
mm in diameter
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Retinal vessel assessment
From the disc, followeach arcade of vessels(a paired artery &
vein) peripherally Look for smooth,
gradual tapering
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Retinal Vessel Assessment:Distinguishing arteries & veins
Arteries
Bright red
Narrower
Bright light reflex
Veins
Darker red
Wider
Inconspicuous orabsent light reflex
Retinal Vessel Assessment
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etinal Vessel ssessment Abnormal vessel caliber changes:
arteriovenous crossing changes
A-V Nicking
A-V Banking
Example of A-V
banking & nicking
Knick
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Assessment of retinal
background Normal variation
of retinal
background
pigmentation
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Assessment of retinal
background View retinal
background
to make sure thereare nohemorrhages,exudates, or otherabnormalities
Abnormal retinal backgroundwith hemorrhages & exudates
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Assessment of the maculaTwo ways to find the macula
1. Direct theophthalmoscope 2
disc diameterstemporal to the disc,or,
2. Ask the patient to
look at the light
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Direct Ophthalmoscope
Systematic evaluation of the retina
Optic disc
Retinal blood vessels
Retinal background
Macula
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The Ocular Examination
Visual acuity
Pupils
Motility Visual Fields
Inspection of the external eye and
anterior segment Red reflex and retinal examination
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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 segmentabnormalities, and tutorial session atVanderbilt Eye Institute