2013A - Physical Examination of the Eyes

History and Physical Examination of the Eyes July 7, 2010

Rizalino Jose F. Felarca, M.D. LECTURE OBJECTIVES At the end of the lecture, the student should be able to: 1. 2. 3. 4. 5. 6.

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 A.

Includes location, severity and circumstances surrounding onset

C.

Associated Signs and Symptoms

Extract an Accurate Ocular history Recognize/ identify normal anatomy of the eye Perform Visual Acuity exam for far and near (vision) Perform Digital Tonometry Recognize/ differentiate normal from abnormal conditions Identify the components of an 8 part eye exam

HISTORY TAKING 

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Follows the general format of history taking and symptom analysis Can be started with an open-ended question such as “How is your vision?” of “Have you had any trouble with your eyes?” Pursue further details vis-avis symptom analysis if patient verbalizes an eye/ vision problem Chief Complaint

MD: Ano pa ang nararamdaman mo? Px: Lumabo ho ang paningin ko…masakit na masakit ho ang ulo ko…at pulang pula daw ho ang aking mga mata sabi nila.

These usually are: 1. 2. 3. 4.

D. Consultations/ Treatment MD: Nagpacheck-up ka ba sa duktor? May gamot ka bang ipinatak o ininom?

“There is only one chief, the rest are mere Indians.” -

Redness Photophobia Discharge Double vision

Px: Sabi ng kapitbahay ko…baka sore eyes, kaya nilagyan ho ng gatas ng ina. Sabi nga ng kumare ko, ihi daw ang dapat ipatak eh.

Dave Gellogue, M.D. UERM „77

MD: Ano po ang problema?

MD: Opthalmologist ba ang kumare mo? *

Px: Doc, masakit ang aking mata? 

MD: Alin, kanan o kaliwa?

 B.

Onset, Duration and Severity of symptoms

MD: Kelan mo pa naramdaman ito?

E.

ask if any medications were taken or any consultation was sought * - such remarks are to be used sparingly and with discretion, since patients react in different ways (be nice )

Aggravating/ Alleviating factors Px: Doc, pag umuubo o‟ umiiri ako lalaong sumasakit, pero pag umiinom ako ng Ponstan, gumagaan ng konti ang pakiramdam ko.

Px: Mga tatlong araw na po. MD: Paano nagsimula ito? Px: Nagkusot ho ako ng mata…tapos sumakit na. MD: Gaano kasakit ba ito?

F. 1.

Px: Sa sobrang sakit po, nasuka ho ako.

2. 3.

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Other pertinent questions Systemic signs and symptoms – Diabetes Mellitus, Hypertension, cardiac disease, etc Any intake of drugs – clopidogrel or other blood thinners, etc. Prior surgery and treatment

Characterizes the chief complaint according to duration, frequency, intermittency and rapidity of onset

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PHYSICAL EXAMINATION

FINDINGS

eyelashes against the globe, specifically the cornea IV. causes corneal irritation and encourages ulceration  Distichiasis V. Manifested by accessory eyelashes, often growing from the orifices of the meibomian glands VI. May be congenital or the result of inflammatory metaplastic changes

FRESHIE FLASHBACK: 4 “actions” involved in physical examination – Inspection, Palpation, Percussion and Auscultation (for the eyes, inspection and palpation are done)  Inspection/ “Eyeballing” (further discussed under external

eye exam)  

This presumes that you have done history taking on your patient. LOOK at the lashes, lids, and palpebral openings and note for abnormalities

The 8-part Eye Exam I. Visual acuity Each eye is evaluated by itself, since binocular testing will not reveal poor vision in one eyes

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a. Snellen Test uses a chart with different sizes of letters or forms shows how accurately you can see from a distance It is viewed at 6 metres (20 feet). A visual acuity of 6/6 indicates that the chart was viewed at 6 metres, and the lowest line that could be read was labelled 6. Illiterate „E‟ chart: Utilizes tumbling "E" letter for illiterate patients and for children.

a. Lids o Note position in relation to eyeballs as well as color of the skin o Inspect for presence of edema and lesions NORMAL  Are modified folds of skin that can close to protect the anterior eyeball  The upper eyelid ends at the eyebrows and the lower lid merges into the cheels SIGNIFICANT FINDINGS

b. Jaeger eye chart For reading up close and determining near vision As you progress to larger lettered paragraphs, the lettering size increases for lesser visual acuity.

Note: Uncorrected VA is measured w/o glasses or contact lenses. Corrected acuity means these aids were worn.

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c. Pinhole test Viewing the Snellen chart through a placard of multiple tiny pinhole – sized openings prevents most of the misfocused rays from entering the eye.

II. External eye exam a. Position and alignment of the eyes o Stand in front of the patient o Survey the eyes for position and alignment o Note the presence of protrusion as in Graves‟ disease (see section on Proptosis) b. Eyebrows o Inspect and note quantity and distribution o Also note scaliness or any changes in the underlying skin c. Lashes NORMAL  Eyelashes project from the margins of the eyelids and are arranged irregularly.  Upper lashes – more numerous and turn upward  Lower lashes – turn downward SIGNIFICANT

 Trichiasis III. inversion and rubbing of the

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a.

 ECTROPION VII. Sagging and eversion of the lower lid VIII. Usually bilateral and frequently found in the elderly IX. May be iatrogenic (E.g. From improperly sutured laceration)  ENTROPION Turning inward of the lid May be a result of aging (involutional), conjunctival and tarsal scar formation (cicatricial), or congenital  External Hordeolum An infection of the glands of the eyelids, usually due to staph Involves the Zeis‟s or Moll‟s glands Internal hordeolum: involves the Meibomian glands  Chalazion chronic granulomatous inflammation of the Meibomian glands characterized by painless localized swelling lacks the acure inflammatory signs of hordeolums  Graves’ Disease Lid retraction is a pathognomonic symptom of thyroid disease, associated with exopththalmos Accompanied by hypertrophy of recti muscles causes puffiness of the lids controlled with meds Palpebral Fissure o Reflects the adequacy with which the lids close o Especially notable in conditions were the eyes are unusually prominent, when

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there is facial paralysis, or when the patient is unconscious NORMAL

SIGNIFICANT FINDINGS

 The elliptic space between the two open lids  Terminates at the medial and lateral canthi (the angle at either end of the eyelid)  Down Syndrome – upstarting palpebral fissures

NOTE: Based on Bates, the lashes and palpebral fissures are included under the examination of eyelids. This trans follows the format presented to the class, so please be guided accordingly.  b.

Proptosis o Displacement of the eyeball forward due to any increase in the orbital contents o Hallmark of orbital disease o Not in itself injurious unless the lids are unable to cover the cornea o E.g. Graves‟ disease – accompanied by lid retraction

a. -

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b. -

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Lacrimal Apparatus o Inspect the regions of the lacrimal gland and sac o Note the presence of swelling

d.

Conjunctiva and Sclera o Ask the patient to look up as you depress the lower lid with your thumb o For a fuller view, spread the lids with your thumb and finger then ask the patient to look to each side and down o Inspect the color and vascular pattern o Look for nodules or swelling

e.

Cornea and Lens o Use oblique lighting o Inspect for any opacities (e.g. cataract)

f.

Iris o While inspecting the cornea and lens, inspect the iris o Markings should be clearly defined o With the light shining directly from the temporal side, look for a crescentic shadow on the medial side of the iris (in a normal iris, this is not seen since it is fairly flat)

III. Pupillary exam  Basic exam: pupils = symmetric and reacts to both light and accommodation  Normal pupil size: 3-4 mm

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Swinging Penlight Test for Marcus Gunn Pupil As a light is swung back and forth in front of the two pupils, one can compare the direct and consensual reactions of each pupil. Since the direct reaction is usually stronger than the consensual, each pupil should immediately constrict slightly more as the light falls directly on it.

IV. Motility exam Objective: evaluate the alignment of the eyes and their movements both individually (ductions) and in tandem (versions). a.

Testing Alignment Simple test of binocular alignment: performed by having the patient look toward a penlight held several feet away. A pinpoint light reflection or reflex should appear on each cornea and should be centered over each pupil if the two eyes are straight in their alignment. Cover test: Patient is asked to gaze at a distant target with both eyes open. If both eyes are fixating together on the target, covering one eye should not affect the position or continued fixation of the other eye. To perform the test, the examiner suddenly covers one eye and carefully watches to see that the second eye does not move (indicating that it was fixating on the same target already).

b.

Testing Extraocular Movements The patient is asked to follow a target with both eyes as it is moved in each of the four cardinal directions of gaze. note the speed, smoothness, range and symmetry of movements and observes for unsteadiness of fixation (eg. Nystagmus)

V.

Tonometry Measurement of intraocular pressure (IOP) Measured in mmHg normal IOP is around 10-21mmHg High IOP may indicate glaucoma or ocular hypertension Low IOP may indicate ocular hypotension observed in conditions like retinal detachment and iritis

NOTE: The following were not lectured to us but is part of the eye exam, according to Bates… c.

Direct response to light refers to constriction of the illuminated pupil reaction may be graded as brisk or sluggish To avoid accommodation, the patient is asked to stare in the distance as a penlight is directed toward each eye. Normally a consensual contriction will simultaneously occur in the opposite nonilluminated pupil. This is usually a slightly weaker response.

a. Digital Tonometry use of the examiner‟s fingertips to estimate the IOP

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may be used with uncooperative patients or when there is no instrument available

Procedure: 1. Ask the patient to look down (patient‟s eye must not be closed) while the examiner‟s forefingers (usually the index and middle finger) gently rests on the superior aspect of the eye. 2. The other fingers may gently rest on the patient‟s forehead. 3. The examiner gently and alternately depresses both forefingers on the globe while assessing the tone. Normotensive eye (normal IOP): similar tone to the tip of the nose Increase IOP: tone of glabella Decrease IOP: tone of the lips 4. Repeat the same procedure with the other eye.

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abnormal field can indicate a problem in the retina, optic nerve, or visual pathway

Performing confrontational field test: a.

Screening – starts in the temporal fields (most defects include these areas) 1. 2. 3. 4. 5. 6.

Imagine the patient‟s visual fields projected onto a glass bowl that encircles the front of the patient‟s head Ask the patient to look with both eyes into your eyes While you return the patient‟s gaze, place your hands 2 feet apart, lateral to the patient‟s ears Instruct the patient to point to your fingers as soon as they are seen Slowly move the wiggling fingers along the imaginary bowl and toward the line of gaze until the patient identifies them Repeat this pattern in the upper and lower quadrants

When the patient sees both sets of fingers at the same time, the fields are normal. b.

Further Testing – when a defect is detected; one eye at a time is tested. 1.

b. Goldmann Applation Tonometry Instrument: goldman applation tonometer attached to the slitlamp Measures the amount of force required to flatten the corneal apex by a standard amount o The higher the intraocular pressure, the greater force required -

More accurate than Schiotz tonometry

c. Schiotz Indentation Tonometry Advantage: simple, inexpensive, easily portable handheld instrument Disadvantage: requires greater expertise

2. 3.

When testing for the eye with a suspected temporal defect: ask the patient to look into your eye directly opposite to that of with defect while the normal eye is covered (e.g. a patient suspected with left temporal defect covers her right eye while the left eye looks directly to your right eye). Slowly, move your wriggling fingers from the defective area toward the better vision, noting where the patient first responds. Temporal defect suggests nasal defect on the opposite eye. Examine the opposite eye similarly moving from the anticipated defect toward the better vision.

Note: since both Goldman applation tonometry and Schiotz

tonometry uses devices that touch the cornea, they require local anesthetic and disinfection of the instrument tip prior to use. VI.

Confrontation tests

Visual field portion of a subject‟s surroundings that is visible at any one time measures sensitivity: ability to detect light thresholds at different locations

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Visual field defects

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VII. Slit lamp Biomicroscopy

Slit lamp Biomicroscope Is a unique instrument that permits magnified examination of transparent or translucent tissues of the eye in crosssection. Enhances the external examination by allowing a binocular, stereoscopic view, a wide range of magnification, and illumination of variable shapes and intensities to highlight different aspects of ocular tissue. Is indispensible for the detailed examination of virtually all tissues of the eye. It is routinely used for examination of the anterior segment, which includes the anterior vitreous and those structures anterior to it. VIII. Opthalmoscopy

OPTHALMOSCOPY / FUNDUSCOPY Is the examination of the posterior segment of the eye, performed with an instrument called the opthalmoscope. 2 Types of Opthalmoscopy a) Direct Opthalmoscopy  Allows one to focus on the retina itself  Hand-held direct opthalmoscope provides a monocular image of the ocular media and fundus magnified 15 times normal.

Tenks poWz sa mga sumusunod: Boss Bob: for trying to procure the ppt for us, salamuch for your hard work preZ, Marco: thanks for the ppt pics, without which this trans may not have existed… Pabati naman kina… Kimmy-dora, Ricky, “schwing”, Boss A, Friend, Jayms, Partner, Ue-Rm: kilala niyo naman kung sino kayo (lalo na yung huli), thanks for the laugh trips and the lunch “parties” XD Mariel andAboy: ayan ha, pilit na pilit! Good luck sa boards! Wag sana tumaas PF niyo kahit may license na… To my prospective seeses: ano kayo cohort? Haha..tandaan, walang bibitiw! Transmates: beh, buddypoke and tol: salamuch sa inyong hardwork! Let’s give each other a pat on the back…*aray*…wag naman ganyan kalakas…( Bully: habang ginagawa ko ang shoutout na ‘to naamoy ko na birthday mo…sige na nga…Merry Christmas! ‘Wag ka na manulak sa stairs ha, may elevator shaft naman eh… God bless sa exams batchmates!!! Go lang ng Go! --Cooks to go-Hi sa mga taga bahay ni kuya!!!  Hi groupmates!!!  Hi transmates!!! Yey, 1st trans ko to. Hehehe 

WAG KANG MANLALANDI KUNG HINDI MO MAHAL AT WAG KANG MAGPAPALANDI KUNG ALAM MONG MASASAKTAN KA LANG. – isang ate sa jeep.

OVERHEARD OUTSIDE UE: Hello Ger? Asa na ka? Pasundo n ko diri sa UE..Ha? Naa pa ka sa balay? Diri dong sa UE, sa atubangan ha? Sa may waiting shed.. Cge..  (thanks nikki for translating)

b) Indirect Opthalmoscopy  So called because one is viewing an “image” of the retina formed by a hand-held “condensing lens”.  Provides a much wider field of view with less overall magnification (approximately 3.5x using a standard 20-diopter hand-held condensing lens). NOTE: Please refer to the powerpoint for the pics. Let‟s save ink and paper! (mahal ang libro eh ) -----------------------------------FIN------------------------------------REFERENCES: Bates‟ Guide to Physical Examination Vaughan & Asbury‟s General Ophthalmology 8 Part eye exam handout Lecture PPT

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