OPHTHALMIC ASSESSMENT

Nehal MANDOUR Associate Specialist

Urgent Care Lead Clinician REI - PLYMOUTH

Patients presenting with an eye complaint may strike fear in some practitioner's hearts as they recall student days standing in dimly lit rooms looking at incomprehensible machines which obscure both patient and doctor, wondering what on earth was going on.

OUTLINE

• Anatomy overview

• Instruments used for eye exam

• History taking – important?!

• Assessment of Eye Functions

• Assessment of Eye Structures

General appearance

The eye is one of the few organs of the body which can be looked at both outside and in and whose basic function can be assessed using simple desk-top tools.

Cross section appearance

EYE ASSESSMENT

Good History Taking is Essential

• Complaint

• History of present complaint

• Past ocular history

• Medical history

• Drug history

• Family history

• Allergy

Is History Taking REALLY Important?

• http://www.youtube.com/watch?v=zKjcbQUaB4E

History of Present Complaint Patient initial report of condition

Which Eye

Right Vision Left Vision

Pain (sharp, fb sensation, ache, throbbing, pressure, headache) Duration

Analgesia taken ?

Lid abnormality (lump ,droop, oedema) Duration

Trauma (high velocity, organic, power tool, chemical) When

Change in Vision: (Please circle.) Duration

Blur: all over, central Peripheral

shadow (where)............

Distortion Onset: sudden days, weeks, months

Intermittent, Persistent

Progression: stable, getting worse

Associated pain headache

Discharge (sticky, watery) Duration Floaters (how many) Duration

Flashes (day, night) Duration

Redness(where , how did you notice it) Duration

Diplopia (vertical, horizontal, both eyes, one eye) Duration

Associated with headache?

Photophobia Duration

GP ref for GCA (only if vision affected or diplopia- assess as above)

ESR....... Requested?

CRP......... Requested?

• Previous Ocular History: • Glasses wear ( distance ,near) , Contact lens wear

• Previous eye condition / treatment

• Previous ocular trauma or surgery

• Level of Visual Acuity in involved eye before injury

• Level of vision in the other eye.

• Medical History: • Routine +

• Use of anticoagulant medications ---- especially over-the-counter medications containing aspirin

• Status of tetanus prophylaxis

• Any difficulties with previous anaesthesia or surgery

Instruments used for Eye Examination

In General Practice

• VA Chart • Pen torch +/- blue filter • Magnifying lens • Slit lamp(?) • Hand-held direct Ophthalmoscope • Drops:

– Fluorescein drop / fluorescein impregnated paper – Topical anaesthesia – Topical short acting mydriatics preferably G.Tropicamide

• Ruler

EYE EXAMINATION

• Visual Acuity

• Pupil Reflexes

• Visual Field

• EOM

• Pressure

• Anterior segment: • Lid /Lacrimal system

• Conjunctiva /Sclera

• Cornea

• Anterior Chamber

• Iris / Pupil

• Lens

• Orbit ( If you can get that far – GREAT )

• Posterior examination • Red Reflex

• Fundus exam – Vitreous/Disc/Retina/Macula

Examining Eye Function

1.Visual Acuity

• First step (EXCEPT in CHEMICAL INJURY)

• Prior to shining light or manipulating the eye.

– Injured eye and uninjured eye

– Best corrected (ideal)-i.e. with correct glasses

– Pinhole: important ( reduction in vision with the pinhole can be a sign of ophthalmic pathology rather than a refractive error )

– Pain relief, Tissue paper, Blinking, Guessing!

• Each eye is tested independently.

• "Best corrected vision."

• Ask patients to read

smallest line they can see.

• Repeat with the other eye.

Recording Visual acuity

• Rt eye and Lt eye

• Unaided vs with glasses

• With pin hole ( Improvement vs no improvement)

– 6/6 ………6/60 (+ or -)

– Counting fingers : CF @ ……. Meters

– Hand movement : HM

– Light perception: LP

– No light perception : NPL

( Do not write: BLIND or UNABLE TO SEE)

2. Pupillary Light Reflexes

• Darkened room • Ask the patient to fix on a distant object (to avoid the

accommodation reflex that causes constriction of the pupil). • Shine bright a pen torch into one eye and assess if the

pupil constricts. • Then repeat this in the other eye. • Observe for the :

– Direct response (constriction of the same pupil) – Consensual response (simultaneous constriction of other

pupil)

NORMAL

“Swinging Flashlight" Test

• Ask the patient to fixate on an object in the distance, and then direct a bright light to one eye.

• Move the light quickly to the other eye and repeat

the process, swinging the light from eye to eye. • A normal reaction would be a brisk pupil

constriction of the stimulated eye; as the light is moved to the fellow eye it should constrict (or stay constricted).

• If it dilates rather than constricts, this is known

as an RAPD. A positive finding is a strong indicator of retinal or optic nerve pathology.

RAPD

Assessing Right Eye Assessing Left Eye

3.a.Peripheral Visual Field Assessment • Sit at the same horizontal and vertical level as patient , 1 meter away • Ask patient to close one eye and you close your eye facing it • Ask patient continue looking at your eye without moving eyes while you

hold up your fingers and ask patient “How many fingers you can see?” in each quadrant.

• Repeat with your other eye.

3.b. Central Visual Field • Look at my face

(Is any part missing or blurred?)

• Amsler chart

RIGHT total VF defect

•Anterior Ischaemic optic neuropathy

•Optic Neuritis

•Vitreous Haemorrhage

•Total Reinal Detachment

•Hysterical ( functional)

Central scotoma (macula)

•Macular Degeneration

•Macular oedema, haemorrhage

•Macular hole

•Optic Neuritis

•Central Cataract (rare)

Lower altitudinal VF defect

=Respecting the horizontal midline

•Superior Branch retinal artery Occlusion

•Superior Branch retinal Vein Occlusion

•Anterior Ischaemic

•Advanced glaucoma

••Superior retinal detachment

4. Ocular Movements / Alignment

• Corneal Reflex • Extra ocular movement in all directions of gaze • Accommodation

Ocular Motility a. Corneal Reflex

• Use pen torch to create a light reflex on cornea.

• Normal corneal reflex should fall in the same position in each eye

• Misalignment:

– Esotropia: Convergent squint

– Exotropia: Divergent Squint

– Hypertopia: one eye is higher than the other

– Hypotropia: one eye is lower than other

Extra ocular Muscle movement in all directions of gaze

Each of the 6 positions of gaze isolate the action of each of EOM

SO '4', LR '6', all the rest '3'

Ocular Motility c. Accommodation

• The room light should be turned on.

• Ask patient to gaze to a far wall.

• Tell them that as soon as they see the your finger /pen/other object, they should focus straight on it.

• Bring your finger directly in towards the patient's

nose.

• This will cause :

– the patient to look cross-eyed and

– the pupils should constrict briskly (Failure to do so is known

as light-near dissociation.)

EYE STRUCTURE Assessment

Anatomical examination Work systematically from front to back.

Lid/Lacrimal • Haematoma / Swelling/ Signs of infection

• Wounds : Lacerations ( full or partial thickness ) esp. to margin / lacrimal puncti or canaliculi /Puncture wounds

• FB

• Position:

– Ptosis ( drooping)/ Retraction

– Ectropion / Entropion

• Lagophthalmos (inability to close eye fully )

• Lumps and bumps (cysts, warts, chalazion, BCCs, SCCs)

• Skin rash / ulceration

• Lashes ( maldirected-rubbing)

• Margin (inflammation- Blephritis)

Lid Haematoma (Black Eye) • The most common type of blunt eye injury

• Usually innocent • ALWAYS exclude more serious conditions:

– Associated globe or orbit trauma: examine the integrity of globe before lids become oedematous – Anterior fossa fracture: assoc. subconj. hge without a posterior limit

– Basal skull fracture: characteristic bilateral ring haematoma= panda eyes)

Eyelid lacerations REFER

• Deeper lacerations,

• Involving the lid margin

• Involving lacrimal punctum/canliculus

• Any associated tissue loss

Allergic lid oedema

Ectropion

Entropion

Rubbing lashes

Ptosis Assessment

• Lagophthalmos

(ask patient to tightly squeeze eye lids)

• Lid retraction (visible sclera above the superior limbus+/- below inferior limbus)

Lumps and Bumps

Lacrimal sac Inflammation ( Dacryocystitis)

Acute

Chronic

+ve regurge

NOT Lactimal

Orbit

• Look

• Listen

• Feel

Look

• Bruises

• Chemosis of conjunctiva

• Lid swellings/ haematoma /emphysema

• Nose bleeds

• Check the EOMs

• Proptosis (exophthalmos)

• Enophthalmos

Look

• Proptosis or Enophthalmos: – Direction

– Severity:

• plastic ruler resting on lateral canthus

• Ideally in both erect and supine positions

• Proptosis :

– Readings > 20mm

– Difference of 2mm between both eyes regardless absolute value.

Retrobulbar Haemorrhage

• When an orbital vessel ruptures blood products into the orbit.

• Since closed space, any added contents increase pressure

inside the orbit potential damage to the ocular structures.

• Look for: – non-pulsating exophthalmos with – resistance to retropulsion, – elevated IOP, – EOM restriction, – central retinal artery pulsation (indicating a possible impending central retinal artery occlusion), – choroidal folds, and possibly signs of optic neuropathy.

Orbital Floor Blow-out fracture • Symptoms

Vertical (UP + Down Gaze) diplopia:

• mechanical entrapment of

– inferior rectus

– inferior oblique belly

– Adjacent fat / CT

• Hge + oedema of orbital fat/ CT

• Direct injury to muscle.

• look for :

• infraorbital hyposthesia and

• enophthalmos.

• Limited vertical mobility

• Intraocular damage

ORBITAL CELLULITIS

• Potentially blinding + life threatening especially in children

• Source of infection:

– Spread from periorbital tissues: sinuses, face, eye

– Direct inoculation of orbit from trauma or surgery

– Haematogenous spread from bacteraemia

ORBITAL CELLULITIS • Cardinal signs:

– Proptosis

– Restricted eye movement

• Other signs:

– Patient is unwell, malaise

– Fever, headache

– Tenderness over sinuses

– Pain on eye movements

– Lid oedema and Chemosis

– Reduced vision/diplopia

– RAPD

Preseptal Cellulitis

• NO proptosis

• NO limited eye movement

• NO reduced vision ( after clearing any discharge)

• Patient is NOT toxic

• (Fever , lid oedema and hyperaemia, facial pain)

Feel

• Pulsations /Thrill Carotid-cavernous Fistula

• Evaluate orbital integrity:

– Palpate the orbital margins for a bony step-off that would be a clear sign of a fracture.

– Palpate the eyelids for crepitus or subcutaneous

emphysema. A positive finding indicates that air from a sinus

has formed pockets within the orbital tissues.

Feel

• Compare ipsilateral and contralateral cheek and forehead sensitivity:

Listen

Audible Orbital Bruit

Carotidocavernous Fistula ( High velocity fistula) • an abrupt onset

• usually caused by a traumatic basal skull fracture.

• Look for:

– an audible orbital bruit,

– pulsatile proptosis,

– chemosis,

– orbital swelling,

– elevated IOP,

– ophthalmoplegia,

– and retinal vessel congestion.

Conjunctiva

Conjunctiva

– Look for: • Local or generalised inflammation

• Discolouration

• Lesions

• wounds

– Pull down lower lid and evert upper lid

Chemosis (oedema)

Conjunctival Abrasions/ Lacerations

• Abrasions: – fluorescein staining and – may produce some degree of subconjunctival haemorrhage

• Lacerations

– significant haemorrhaging and – typically have exposed white sclera. – conjunctival edges have a tendency to be rolled due to the elastic nature of conjunctive.

• If a laceration is large, consider suturing, but most lacerations will heal without surgical repair.

• Always :

– Inspect the fornices thoroughly

– Evert the eyelids to look for

occult palpebral conjunctival FB

which can cause corneal track marks.

Sclera

Look for : • Colour • Wounds • inflammation

Sclera

• Yellow sclera (icterus): in liver or blood disorders that cause hyperbilirubinemia.

• Muddy-brown discoloration common among dark / African people (a variant of normal).

SCLERITIS

• Very painful (BORING+++)

• More florid inflammation

• Distortion of pattern of vascular plexus with loss of radial pattern

• No blanching with Phenylepherine 10% drops

Scleral Lacerations Refer

Cornea

Cornea

– Look for :

• Clarity

• Wounds/FB

– Stain with fluorescein • Abrasions/ ulcers

• Seidle test (if suspecting penetrating

injury)

• Corneal and conjunctival FB

• Corneal abrasions negative Seidel test.

+ve fluorescein stain • Corneal laceration

+ve seidle test

• Corneal ulcers and Keratitis

• Corneal oedema ( cloudy cornea)

The Anterior Chamber

Anterior Chamber

• Content: – Blood – Pus – FB – Lens

• Depth: compare both eyes – Shallow – Deep – Irregular

AC contents

Anterior Chamber Depth

• Iris closer to cornea

• Eclipse sign

DEEP AC angle

DEEP AC angle

Shallow AC angle

Closed/very narrow AC angle

Fully illuminated = Grade4

>2/3 illuminated = Grade3

1/3-2/3 illuminated=Grade2

<1/3 illuminated=Grade1

Iris and Pupil

• Look for:

– Size & shape of pupil margin

– Normal light reflex/ RAPD

– Distortion towards limbus ( Peaked Pupil)

– Iris defects

– Normal pupil ( Round regular reactive equal in size, no RAPD)

Traumatic iritis

• History of trauma is critical

• Presentation: – photophobia in both the involved + uninvolved eye

(because of consensual pupillary constriction), – perilimbal injection, – cells and flare in the anterior chamber.

Pupil Sphincter Tear

Peaked Pupil

Iridodialysis

• Detachment of the iris root from the ciliary body

• Presentation: – irregular pupil shape- D shaped, – pseudopolycoria, – diplopia.

• Be aware of

other iris defects

Different iris colour

• Congenital

• Acquired ( History of trauma + retained iron FB)

Lens

• Clarity

• Position • In place

• AC

• PC

• In Pupil

• Stability: • ‘Tremors’

Clarity/Position

Posterior Segment Examination

Posterior Segment Examination

• Look for:

– red reflex:

• Bright

• Dim

• Grey

• Absent

– Details:

• Optic nerve

• Retina

• Vessels

• Vitreous

Direct Ophthalmoscopy Get to know your scope FIRST

Direct Ophthalmoscopy(1)

• Red Reflex: – With lens power of

ophthalmoscope turned to 0 stand at arm's length from the patient and shine the light from the ophthalmoscope into the pupil.

• Normal red reflex: – Yellow/orange/bright red

glow (reflection from choroidal vessels).

– The area is round in shape and evenly lighted

– Indicates no obstruction between you and patient retina

• Abnormal reflex – Any opacity =dark area

– In retinal detachment

reflex appears grey instead of red

Do you see clear red ?

• Fundus: – When you do get a red

reflex, move slowly as close as possible towards patient

– Your forehead touches your thumb which is used to lift upper lid of eye examined.

Direct Ophthalmoscopy(2)

• Fundus:

– The refractive power of the examiner and patient should be compensated for by adjusting the lens power of ophthalmoscope.

– Ask patient to look at a distant object .

– For right fundus

examination: • Hold instrument with right

hand

• Use your right eye

• Approach patient from the right side

Various Findings

Pre-retinal Haemorrhage/ Vitreous Hge

• Visual acuity can be severely reduced if it lies in front of the macula.

• Gravity will cause the blood to settle into the quintessential "keel-shape" with the blood being darker on the bottom.

• In Vitreous hge : very dim red reflex

(Traumatic) retinal detachment

Purtscher's Retinopathy

• An injury that includes either : – major chest compression (air bags) – or head trauma

• Signs:

– cotton-wool spots and hemorrhages along the retinal arcades

• This diagnosis is driven first by history and then by the clinical presentation.

• Although not completely understood, Purtscher's retinopathy may be

due to arterial and venous back-flow into the retinal vessels. • Patients should be reassured that the condition tends to resolve

without treatment, but they should be dilated every 2 to 3 weeks until resolution occurs

• Optic disc atrophy

• Disc oedema

Optic nerve avulsion

• Avulsion can occur after severe trauma or relatively minor insults, but always results in devastating loss of vision.

Central / Branch Retinal Vein Occlusion

Central Retinal Artery Occlusion

Putting it all together

• Know your anatomy

• History is of great importance

• Assess function of the eye

• VA/Pupil/VF/EOM/IOP

• Assess structure of eye from outside in.

• Lid /lacrimal/orbit

• Conj/sclera

• Cornea

• AC

• Pupil /iris

• Lens

• Red reflex /fundus