Inspection:
Eyelids:
- What may you notice on the eyelids?
- What is an entropion?
- What is an ectropion?
Lumps (benign or malignant)
Oedema
Cellulitis
Eyelid turns inwards - eyelashes continuously rub against the cornea causing irritation.
Eyelid turns outward - inner eyelid surface exposed and prone to irritation.
Inspection:
Eyelashes:
- What is a loss of eyelashes associated with?
- What is trichiasis?
Diffuse conjunctival (injection) redness - what does this indicate?
Circumcillary injection:
- What is it?
- What does it suggest?
- What are some causes?
Malignant lesions
Abnormally positioned eyelashes that grow back toward the eye, touching the cornea or conjunctiva.
Dilated inflamed blood vessels affecting conjunctiva in circular pattern around the cornea
Intraocular inflammation
Acute angle close glaucoma
Uveitis
Inspection:
Discharge:
- What does watery discharge suggest? - 3
- What does purulent discharge suggest?
Hyphema:
- What is it?
- Where is it found?
- What usually causes it?
Hypopyon;
- What is it?
- Where is it found?
- What is it associated with?
Allergic and viral conjunctivitis
Normal physiological production (e.g. reaction to corneal abrasion/foreign body) --- Bacterial C ----- Inferior settled layer of blood Anterior chamber Trauma
Inferior settled layer of pus
Anterior chamber
Severe corneal ulcers
Endophthalmitis
Anterior uveitis
Inspection:
Periorbital erythema and swelling:
- What do we call this when it is anterior to the orbital septum?
- What do we call this when it is posterior to the orbital septum?
What signs indicate there is a foreign body?
Preseptal cellulltis
Orbital cellulitis ---- You may see it embedded in cornea or sclera Redness Pain Watering 'Foreign body sensation'
Inspection:
Corneal abrasion:
- Apart from redness and pain, what is a distinguishing sign?
Corneal ulcer:
- Apart from redness and pain, what is a distinguishing sign?
- What may the patient say their vision is like?
Photophobia
Photophobia
Hazy - may appear fluffy and irregular
Inspection:
What does a peaked pupil suggest?
Asymmetric pupils:
- If the pupils are more pronounced in bright light, what pupil is abnormal?
- If the pupils are more pronounced in the dark, what pupil is abnormal?
- What can cause a large pupil?
- What can cause a small and reactive pupil?
Trauma - suggests injury to the globe - doesn’t affect vision
Larger pupil
Smaller pupil
Oculomotor nerve palsy
Horner’s syndrome
Visual acuity:
What is used first to assess visual acuity?
What should you not forget to ask about?
Snellen chart
Ask if they usually wear glasses? - Distance glasses need to be worn - measuring corrected vision
Visual acuity:
Snellen chart:
5 steps:
1. How far away do they stand from the shelled chart?
- What should you ask the patient to do? - 2
- Record the result!
- You can get the patient to look through a pinhole to see if vision improves. If it improves, what does this suggest?
- Repeat previous for other eye
6 metres
Ask the patient to cover one eye and read the lowest line they are able to.
Reflective component to the patient’s poor vision
Visual acuity:
Recording visual acuity:
Results are written as a fraction e.g. 6/6
> What does the numerator and denominator mean?
> If a patient reads their lowest line but get 2 wrong for example, how would you record that?
> What is a patient gets more than 2 wrong?
> What else do you need to remember when recording the result?
QUESTION:
> What does 6/60 mean?
Chart distance (numerator) over the number of the lowest line read (denominator).
6/6 (-2)
Use previous line
6/60 means the subject can only see the top letter when viewed at 6m.
Visual acuity:
Further steps for patients with poor vision:
Step 1:
- Where should the patient moved to?
- How would this change the recording of the acuity?
Step 2:
- Where should the patient moved to?
- How would this change the recording of the acuity?
Step 3 and 4:
- Next 2 step if previous 2 fail?
- How would these be recorded?
Step 5:
- Last test for any type of vision?
- How would this be recorded?
Move to 3 metres
3/denominator
Move to 1 metre
1/denominator
Assess if they can count the number of fingers you’re holding up (recorded as “Counting Fingers” or “CF”).
Assess if they can see gross hand movements (recorded as “Hand Movements” or “HM”)
Assess if they can detect light from a pen torch shone into each eye (“Perception of Light”/”PL” or “No Perception of Light”/”NPL”).
Visual acuity:
How to test for near vision?
What can cause decreased visual acuity? - READ
Ask the patient to cover one eye and read paragraph of small print in a book or newspaper //////////////// - Refractive errors
- Amblyopia
- Ocular media opacities such as cataract or corneal scarring
- Retinal diseases such as age-related macular degeneration
- Optic nerve (CN II) pathology such as optic neuritis
- Lesions higher in the visual pathways
Colour vision assessment:
What is used to assess coloured vision?
Ishihara plates
Colour vision assessment:
What do you ask the patients to look for?
If the patient is unable to read the first test plate, what should be done?
How many plates are there?
How is the result documented?
Look for a number on the plate
Document this
13
13/13 including test plate
Visual fields:
What should you ask the patient to do to begin?
What should you do?
How can you quickly assess central vision?
What object is used as a visual target?
You can test blind spot in the same way as you test visual fields:
- Where do you move the object used instead?
- What does an enlarged blind sport suggest?
Cover one eye and focus on your nose
Mirror the patient
Ask the patient if any part of your face is missing or distorted
Hatpin (or another visual target)
Laterally instead of diagonally
Swollen optic disc (papilloedema) - raised ICP
Eye movement:
What causes eye movement abnormalities?
How do you test for accommodation?
What should happen to the eyes?
H test:
- What does nystagmus suggest?
What endocrine disorder is lid lag associated with?
Nerve palsies
Ask the patient to focus on a distant point, then ask the patient to focus on the object in front of their eyes.
They should converge and constrict.
Vestibular nerve pathology or stroke
Thyroid eye disease
Pupillary reflexes:
What should you do to the room at this point?
How to assess for a direct pupillary reflex?
How to assess for a consensual pupillary reflex?
What does a swinging light test detect?
Explain how this defect presents and why?
CUT THE LIGHTS!!
Look for constriction in the same pupil
Relative afferent pupillary defect
- Normally light shone into either eye should constrict both pupils equally (due to the dual efferent pathways described above).
- When the afferent limb in one of the optic nerves is damaged, partially or completely, both pupils will constrict less when light is shone into the affected eye compared to the healthy eye.
- The pupils, therefore, appear to relatively dilate when swinging the torch from the healthy to the affected eye.
Pupillary reflexes:
Unilateral efferent defect:
- What nerve and ganglion is responsible for pupillary reflexes?
- What may cause this?
- What does the UED mean?
- What about the other eye?
Oculomotor nerve
Ciliary ganglion
Compression of CN3
The ipsilateral pupil is unresponsive
Other eye should be unaffected as afferent pathway (optic nerve) is unaffected and other eye’s pathways are still intact.
Fundoscopy:
Aperture (beam size):
- When is a micro aperture used?
- When is a small aperture used?
- When is a large aperture used?
- When is a slit aperture used?
Filter:
- What is a cobalt blue filter?
- What is the red-free filter?
Viewing fundus through VERY small undilated pupils
—- an undilated pupil
—- dilated pupils
Assessing contour abnormalities of the cornea, lens and retina as it makes it elevation easier to see.
//////////
Used to look for corneal abrasions or ulcers with fluorescein
Look at the centre of the macula and other vasculature in more detail.
Fundoscopy:
Explaining what you are doing
What should you remember to inform the patient about dilating the pupils?
“I will be using a magnifying tool called an ophthalmoscope to look at the front and back of your eyes with the lights off.”“To do this, I’ll need to get quite close to your face. I’ll place a hand on your forehead to prevent us from bumping into each other.”
“I’ll also be using some eye drops to dilate your pupils and to highlight any problems.
The dilating drops will cause your vision to be temporarily blurry and you’ll be more sensitive to light, so you’ll not be able to drive for several hours afterwards.”
Fundoscopy:
What is used to dilate the pupils?
Assessing light reflex:
- What should the diopter dial be set to if you have normal acuity?
- What should the diopter dial be set to if you have a refractive error in your vision without glasses?
- How far away do you keep the ophthalmoscope?
- What do you look for in the eye?
- What causes an absent reflex in adults? - 3 - think of things that stop the view of the retina
- The same thing that happens in children happen in adults. What type of cancer can also cause an absent reflex in children?
Mydriatic eye drops - tropicamide
0
-2
1 arm’s length, a metre
You see a reddish/orange reflection in each pupil
Cataracts *****
Vitreous haemorrhage
Retinal detachment
Retinoblastoma - looks very white when light shone into it
Fundoscopy:
Assessing the anterior segment of the eye:
- What should the diopter dial be set to?
- What 2 things are you looking for?
- What can be applied to the eye to look for the above 2 things?
+ 10/15 in the green number
Corneal disease - ulcer/abrasion
Conjunctivital epithelium damage
Fluorescein dye
Fundoscopy:
Assessing the fundus:
- How do you calculate the number to set the diopter dial to?
- What can be done if things look blurry?
- How do you begin assessing the fundus?
- After finding blood vessels, how do you find the optic disc?
The net result of yours and the patient’s refractive error:
If you have a refractive error but are planning to wear glasses/contact lenses that correct this, assume you have a refractive error of 0 and add the patient’s refractive error to this (e.g. 0 + -2 = -2).
Approach from a 45-degree angle while maintaining the red reflex.
Follow the branches towards the disc
Fundoscopy:
Assessing the optic disc:
What are the 3C’s used to assess it?
Contour
Colour
Cup
Fundoscopy:
Assessing the optic disc:
Contour:
- What should the border look like?
- What would it look like with papilloedema and what does this suggest?
Colour:
- What is the normal colour?
- What does a pale optic disc suggest? - 3
Cup:
You estimate the cup-to-disc ratio.
- What is classed as normal?
- What does an increased ratio suggest?
Clear and well-defined
Optic disc swelling - raised ICP
Orange-pink doughnut with a pale centre - shows good perfusion
Optic neuritis
Advanced glaucoma
Ischaemic vascular events
Cup-to-disc ratio:
0.3
Reduced volume of healthy neuro-retinal tissue, which can occur in glaucoma.
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History9
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Examination28
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Anatomy10
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Periorbital problems10
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Acute Red Eye - Non-emergency13
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Acute Red Eye - Emergencies ****8
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Refractive error4
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Sudden loss of vision - Painful1
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Sudden Loss of vision - Vascular causes12
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Sudden loss of vision - Traumatic causes4
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Subacute loss of vision - Optic Neuritis7
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Sudden loss of vision - Retinal detachment8
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Age-related macular degeneration13
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Chronic open angle glaucoma10
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Cataracts9
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Diabetic retinopathy9
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Toxic ambylopia1
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Congenital and inherited visual impairment7
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Retinitis Pigmentosa2
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Strabismus18
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Corneal Abrasions and Foreign Bodies9
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Severe eye trauma ****15
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Visual Fields17
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Diplopia4
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Nystagmus8
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Pupils7
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Eye and systemic disease10
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Drugs and the Eye3
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Blindness and Partial Sight3
