Ocular Examination (Students)09-10

8/8/2019 Ocular Examination (Students)09-10

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Ocular Examination

F. Francis Ma. L. Cid, MD


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V isual Acuity

Macular function

Distant VA and Near VADone one eye at a timeDone without and with corrective lenses


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V ision at Distance

S nellen chart 20 ft. or 6 m away fromsubjectRecorded as 20/20 (6/6), 20/30 (6/9), or 20/400 (6/120)Pinhole for those not able to read 20/30

For those < 20/200, record VA ascounting fingers (CF), hand movement(HM), light perception (LP), no lightperception (NLP)


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S nellen and Bailey-Lovie Charts


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N ear V ision

T ests accommodationMultipurpose reading card held 14inches (35 cm.) away from theexamined eyeMonocular examRecorded as 20/20, 20/30 or J+1, J+, J2


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Color V ision

Photopic Vision High luminance T hree color receptors

Red conesGreen conesBlue cones

S cotopic Vision Low luminance Rods


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Color Perception Abnormalities

Congenital Protanomaly Deuteranomaly T ritanomaly

Acquired Blue yellow (retina) Red green (optic nerve)


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Ishihara

Chart


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F arnsworth D-15 tests


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G ross Anterior S egment Exam

Done with some form of magnification Magnifying lenses S lit lamp biomicroscope

Eyebrows, eyelids, palpebral fissures Color, scaling, dandruff, hair loss, Sk in texture, color, inflammation, growths Lid position, lid motility


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S lit lamp Biomicroscopy

Microscope for eye examinationFor magnification of the anterior segment of the eyeMay be used for the posterior segmentusing other devices li k e additionalcontact lenses


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Conjunctiva Palpebral

Evert lidsCongestion, foreign bodies, inflammation,tumors

Bulbar Evert lidsCongestion, foreign bodies, inflammation,chemosis, pinguecula, nevi, malignancies



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Episcleral vessels Normally not visible

Run radially, sign of deeper inflammation whencongested

Cornea S ize, light reflex

Foreign body, corneal ulcers Edema, k eratitis S cars (leu k oma, macula, nebula)



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Anterior Chamber Examined with slit lamp biomicroscope Depth of chamber, clarity of aqueous

humor, presence of inflammatory cells or blood

Iris Color, texture, pattern, pigmentation, nevi,

atrophy, tears, openings



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Pupil S ize and shape

Anisocoric (different sizes) Reaction to light

Direct light reflex Examines afferent and efferent arms of the reflex of

examined eyeConsensual light reflex Examines afferent arm of examined eye and the

efferent arm of the opposite eye



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Abnormal pupils Marcus Gunn pupil Adies tonic pupil Argyll-Robertson pupil


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Lens Congenital anomalies Opacities S ubluxation Dislocation


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Extraocular Muscle F unction

Primary position of gazeMidline positions of gaze

Cardinal positions of gaze T emporal (Lateral Rectus) nasal (Medial Rectus) up temporal ( S uperior Rectus)

up nasal (Inferior Oblique) down temporal (Inferior Rectus) down nasal ( S uperior Oblique)


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Extraocular Muscle F unction

T ests for deviations Corneal light reflex Cover uncover test Alternate cover uncover test


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Directions of G aze

primary

Cardinal directions of gaze

I OI OSR SR

LR MR MR LR

IR S O S O IR


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Cover Uncover Test


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Alternate Cover Uncover Test


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EsotropiaExotropiaEsophoriaExophoria

HypertropiaHyperphoriaNystagmus

Extraocular Muscle Deviations


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Exotropia


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Esophoria


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Exophoria


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Intraocular Pressure

Normal value is 22 to 24 mm HgFinger tension Very unreliable requires practice S ubjective Readings descriptive

S oftNormalfirm


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T onometry Indentation tonometry ( S chiotz)

Cornea is indented with a plunger of a setweight

5.5 gm, 7.5 gm, .10 gm, 15 gmT wo readings, one with a different set of weights carried outAny reading less than 4 on the scale requires areading of the next heavier weight


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S chiotz Tonometer


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T onometry Applanation tonometry (Goldmann)

T he gold standardPressure measured is the the force required toflatten a given surface of cornea with a prismReading on the scale is multiplied by 10 to getthe intraocular pressure

Air puff non-contact tonometer S ame principle with applanation tonometryS urface is flattened with a puff of air



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Applanation Tonometry


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G olmann Tonometer Mires


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G onioscopy

Examination of anterior chamber angle Anterior chamber angle cannot bevisualized due to the optical qualities of the corneaContact lens changes the optical

character of the cornea allowing one tosee the trabecular meshwor k , scleralspur, ciliary body band at the irido-corneal angle


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G onioscopy


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V isual F ield Testing

T ests the total integrity of the retinal visualfunction

S tatic (lights fixed, intensity varies)Humphrey automated perimeter Friedman analyser Goldman perimeter

Dynamic (light moves, intensity varies)Goldmann perimeter T angent screenGross confrontation test


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H ill of V ision


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Automated V isual F ield


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R ight H omonymous H emianopia


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Bitemporal H emianopia


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Greater part of the peripheral posterior segment can be examined through a

dilated pupilBest done in a dar k ened roomFor optimal dilation of the pupil , tropicamide 1% or cyclopentolate 0.5%. Phenylephrine 2.5% can be used with caution No mydriatic should be instilled in an eye with

shallow AC; angle closure glaucoma is high ris k

Ophthalmoscopy


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Indirect ophthalmoscope Usually head mounted with +20 to +30 diopter

condensing lens to see image Designed usually for use with dilated pupils Binocular exam Image inverted, 3D, and real Magnification is 3x but the field of vision is bigger

than direct ophthalmoscope giving greater perspective of entire fundus and is helpful inlocating multiple lesions.

S tronger illumination allows light to pass throughopacities

Ophthalmoscopes


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T echnique Observer adjusts lenses on the

ophthalmoscope to correct for the patientsand the observers error of refractionRed numbers for myopiaBlack numbers for hyperopia

Aphak

ic (eyes without its natural lens) eyes(post cataract surgery w/o IOL) examined with+8 to +12 diopter lenses+8 to +10 will focus on anterior segment

Direct Ophthalmoscopy


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T echnique Moving from (+) to () increases the depth

of focus moving from the anterior segmentto the vitreous and retina

Vitreous bodyHemorrhages and floaters localized and noted



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T echnique Optic nerve head

Oval with vertical orientationPink

T emporal side usually lighter Physiologic cup depression at the center Lamina cribrosa Normal cupping from 0 to 80% cupping

Can be pale in optic atrophy or edematous andcongested in pappiledema or papillitis



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T echnique Macula

2 disc diameters temporal to the optic discDar k er (xanthin pigment)Lustrous yellow point (fovea centralis)

Periphery of fundusCan be examined with direct ophthalmoscope up to 1.5mm from the ora serrataObserver moves the ophthalmoscope around to examinethe periphery. Eye and instrument moves as one unit



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Tear film adequacy clinical tests

T ear film testing can be separated intothree areas T ear quantity T ear quality T ear secretion


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Tear Quantity Tests

T ear secretion Basal

Accessory lacrimal glands of Krause andWolfring

ReflexMain lacrimal gland

Average basal tear volume 5 9 microliter with flow rate of 0.5 to 2.2 microliters/ min.Not affected by age


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Tear Quality Tests

T ests for the presence of mucous,protein and tear film stability

Conjunctival biopsyAscertain presence of mucin-producing gobletcells

Qualitative mucous assay

PAS reagent (presence of mucous will reveal adar k purple color)

Protein testing


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Tear F ilm S tability Tests

T ear film ruptures after a certain timeinterval following blin k ing T ear film brea k -up time (BU T ) Wetting of > 25 sec normal Wetting of 15 but < 25 sec transition


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Tear secretion Tests

Ascertain etiology of chronic tearing(epiphora)

Causes of epiphora Partial or comoplete obstruction of excretory canal Increased lacrimal secretionT ear secretion involves pumping action of lids Good anatomic apposition of the patent punctal

openings


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Other tests

UltrasonographyFluorescein angiographyElectroretinography (ERG)Electro-oculography (EOG)Radiologic studies Caldwell view, Waters view, oblique view,

Rhese position, lateral view


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Other Tests

CT scanMRI

Ocular Examination (Students)09-10

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