Transcript OPHTHALMOLOGIC EXAM by: Joanna Pauline Chua

COMMON SIGNS AND
SYMPTOMS OF EYE
DISEASES
Components of the Ocular History
• Chief complaint
–What are the main problems that you are having
with your eyes?
–What other problems are you having with your
eyes?
–Why did you come (or why were you sent) here?
–In what way are you hoping that you might be
help?
–What is it about your eyes that worries or
concerns you?
–What is the main problem that you would like me
to address?
•
• 1. Visual Loss– A. transient visual loss- migraine, ischemia to
eye /visual cortex
– B. acute, persistent visual loss
– C. chronic, progressive, visual loss- refractive,
problems with ocular media or visual pathway
• 2. Diplopia -monocular vs. binocular
• 3. Anisocoria
• 4. Metamorphopsia
• 5. Flashes of light -migraine, occipital epilepsy,
retinal visual pathway lesion
• 6. Floaters- vitreous & retina
• 7. Eye pain- ocular & trigeminal nerve
stimulation
• 8. Proptosis
• 9. Ptosis
• 10. Tearing -inflammation of the cornea,
conjunctiva, eyelids, lids, lacrimal drainage, dry
eye syndrome
Common Complaints
• Decreased blurred central vision (distance,
near or both)
• Decreased peripheral vision
• Altered image size (micropsia, macropsia,
metamorphopsia)
• Diplopia (monocular, binocular, horizontal,
vertical or oblique)
• Photopsias (flashes of light)
• Iridescent vision (halos, rainbows)
• Dark adaptation problems
• Dyslexia (medical inability to read with
normal understanding)
• Color vision abnormalities
• Blindness
• Oscillopsia (apparent movement or
shaking of images)
History of Present Illness
• Onset (sudden or gradual); severity
(improved, worsened or remained the
same); Influences/Precipitating
Condition; Constancy and Temporal
Variation; Laterality: unilateral or
bilateral
– list ocular medications as well
Ocular Medications
• Medication should be recorded
including dosages, frequency and duration of
use, over-the-counter drugs and home
remedies
• Color coded of the cap of container
Green: cholinergic or miotic drugs
(pilocarpine, carbachol)
Red: anticholinergic or dilating cycloplegic
(atropine, tropicamide, cyclopentolate,
phenylephrine)
Yellow: Beta-adrenergic blocking agent
(timoptol)
White: antibiotics, artificial tears,
corticosteroids
Orange: (dorzolamide)
Past medical history
• general state of health
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– principal systemic illnesses
– Vascular disorders commonly associated with
ocular manifestations-such as diabetes and
hypertension-should be asked
– list the patient's systemic medications
– any drug allergies should be recorded
Use of eyeglasses or contact lens
Use of ocular medications in the past
Ocular surgery
Ocular trauma
Systemic Medications
• Use of aspirin, anticoagulant agent,
antibiotics, tranquilizers, narcotics, antiinflammatory agents, anticonvulsants,
contraceptives, or vitamins
Allergies
• Medications
• Environmental agents resulting
in:
Atopic dermatitis
Allergic asthma
Allergic rhinitis, conjunctivitis (hay
fever)
Urticaria (hives)
Vernal conjunctivitis
Family history
– strabismus, amblyopia, glaucoma,
cataracts, and retinal problems, such as
retinal detachment or macular
degeneration.
– Medical diseases such as diabetes may
be relevant as well
COMMON OCULAR SYMPTOMS
• three basic categories:
I. abnormalities of vision
II. abnormalities of ocular appearance
III. and abnormalities of ocular sensationpain and discomfort.
I. ABNORMALITIES OF VISION
• 1. Visual Loss
– due to abnormalities anywhere along the
optical and neurologic visual pathway.
– consider refractive (focusing) error, lid ptosis,
clouding or interference from the ocular media
(eg, corneal edema, cataract, or hemorrhage
in the vitreous or aqueous space), and
malfunction of the retina (macula), optic
nerve, or intracranial visual pathway.
• 2. Visual Aberrations
• Glare or haloes
– -may result from uncorrected refractive error,
scratches on spectacle lenses, excessive pupillary
dilation, and hazy ocular media, such as corneal
edema or cataract.
• Visual distortion
– (apart from blurring) may be manifested as an
irregular pattern of dimness, wavy or jagged lines,
and image magnification or minification.
• Flashing or flickering
– lights may indicate retinal traction (if instantaneous) or
migrainous scintillations that last for several seconds
or minutes.
• Floating spots
– may represent normal vitreous strands
due to vitreous "syneresis" or
separation or the pathologic presence
of pigment, blood, or inflammatory cells.
• Double vision (monocular or binocular)
– (ie, disappears if one eye is covered).
• Monocular diplopia
– Persists when one eye is covered
– It is caused by an optical aberration (cataract,
uncorrected refractive error, presbyopia,
keratopathy).
• Binocular diplopia
– disappears when either eye is covered.
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It results from misalignment of the eyes, and may be caused by:
a central nervous system lesion
an ocular motor nerve lesion
a neuromuscular junction lesion
extraocular muscle lesion
SYMPTOMS
Early
– Difficulty reading, driving, etc
– Straight lines may be crooked
Advanced: central blind spot
Peripheral vision remains
– Independent living skills
Disturbance of vision first
Progressing to diminution
Cataract size & location determine impairment
II. Abnormal appearances
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Ptosis (drooping of the eyelid)
Proptosis (protrusion of the eyes)
Enophthalmos (opposite of proptosis)
Blepharitis
Misalignment of the eyes
Redness, other discolorations,
opacities and masses
Anisocoria (inequality of the pupils)
III. Ocular pain or discomfort
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Foreign body sensation
Ciliary deep pain
Photophobia (pain that is
present upon exposure to light)
Headache
Burning
Dryness
Itching
Asthenopia (eyestrain)
Abnormal ocular secretions
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Lacrimation
Epiphora (actual
spilling of tears)
Dryness
Discharge
VISUAL ACUITY
• numerator - testing
distance from the eye
to the chart being
used (20 feet or 6
meters);
• denominator distance to which the
subject with an
impaired vision can
read the same figure.
Testing Distance Visual Acuity
1.
2.
3.
4.
5.
Ask the patient to stand or to
sit at a designated testing
distance, 20 feet from a wellilluminated wall chart.
Occlude the left eye.
Ask the patient to read aloud
each letter, number or picture
from left to right.
Note the corresponding acuity
measurement shown at that
line of the chart. Record the
VA of each eye separately with
correction and without
correction.
Repeat steps 1-4 for the left
eye, with the right eye
covered.
20 ft
Pinhole acuity test
•
The pinhole admits only central
rays of light which do not require
refraction by the cornea or lens.
• A single pinhole no more than 2.4
mm in diameter should be used.
Testing Pinhole Visual Acuity
1.
2.
3.
4.
5.
6.
Position the patient and occlude the eye not being
tested, as done for the distance acuity test.
Ask the patient to hold the pinhole occluder in front of
the eye that is to be tested.
Instruct the patient to look at the distance chart
through the single pinhole or through any one of the
multiple pinholes.
Instruct the patient to use small hand or eye
movements to align the pinhole to resolve the sharpest
image on the chart.
Ask the patient to begin to read the line with the
smallest letters that are legible as determined on the
previous vision test without the use of the pinhole.
Record the Snellen acuity obtained and precede or
follow it with the abbreviation PH.
Jaeger chart
Used to express near visual acuity.
The test is usually performed at 16 in or 40
cm.
Testing Near Visual Acuity
1. Instruct the patient to hold
the test card at the distance
specified on the card (16 in
or 40 cm).
2. Ask the patient to occlude
the left eye.
3. Ask the patient to read
each word on the line of
smallest character that is
legible in the card.
4. Record the VA for each eye
separately.
5. Repeat the procedure with
the right eye occluded.
Testing Poor Vision
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Count fingers (CF)
Hand moving (HM)
Light perception (LP)
If cannot perceive
light: totally blind
(NLP or no light
perception)
Testing Peripheral Vision
• Confrontation test
• Simultaneous
confrontation test
Test for Pupils
• Direct response to
light
• Consensual
constriction
• Swinging penlight
test for Marcus Gunn
Pupil or relative
afferant pupillary
defect
• The “swinging
flashlight test”
assesses CN II,
CN III
(parasympathetic
innervation of the
sphincter pupillae
muscle), and
sympathetic
innervation of the
dilator pupillae
muscle.
Test for Ocular motility
Testing Alignment
• Cover test: gaze at a distant object. Cover
one eye
Direct Ophthalmoscopy
• Fundus examination
• Anterior segment
examination
• Red reflex
examination
Mydriatic (dilating) Drops
• 2.5% phenylephrine
• 0.5%-1% tropicamide
Specialized Ophthalmologic
Examinations
• Perimetry
systematic measurement of visual field function (the total
area where objects can be seen in the peripheral vision
while the eye is focused on a central point
Specialized Ophthalmologic
Examinations
• Amsler Grid
• tool
for monitoring central
visual field.
• to detect early and
sometimes subtle visual
changes in a variety of
macular diseases such as
age-related macular
degeneration and diabetic
macular edema
Metamorphopsia: macular
edema, submacular fluid
Color Vision Testing
Thank you