Introduction to Clinical Ophthalmology The Eye Examination Chapter

Introduction to Clinical Ophthalmology

The Eye Examination Chapter 1

Anatomy

Anatomy n Extraocular movements n n Medial Lateral Upward Downward

Visual Acuity n General physical examination should include : n n n n Visual acuity Pupillary reaction Extraocular movement Direct ophthalmoscope Dilated exam (in case of visual loss or retinal pathology) Distance or Near Distance visual acuity at age 3 n early detection of amblyopia

Distance Visual Acuity Testing n VA - Visual acuity OD - ocular dexter OS - ocular sinister OU - oculus uterque n 20/20 n n Distance between the patient and the eye chart _______________________ Distance at which the letter can be read by a person with normal acuity

Distance Visual Acuity Testing Place patient at 20 ft from Snellen chart n OD then OS n VA is line in which > ½ letters are read n Pinhole if < 20/40 n

Snellen eye chart Rosenbaum pocket chart

Distance Visual Acuity Testing n If VA < 20/400 n n Reduce the distance between the pt and the chart and record the new distance (eg. 5/400) If < 5/400 CF (include distance) n HM (include distance) n LP n NLP n

Near Visual Acuity Testing n Indicated when Patient complains about near vision n Distance testing difficult/impossible n n Distance specified on each card (35 cm)

Pupillary Examination n Direct penlight into eye while patient looking at distance n Direct n n Constriction of ipsilateral eye Consensual n Constriction of contralateral eye

Ocular Motility Rt superior rectus Lt inferior oblique Lt superior rectus Rt inferior oblique Rt lateral rectus Lt medial rectus Lt lateral rectus Rt medial rectus Rt inferior rectus Lt superior oblique Lt inferior rectus Rt superior oblique

Direct Ophthalmoscopy n Tropicamide or phenylephrine for dilation unless shallow anterior chamber n unless under neurological evaluation n n Use own OD to examine OD n Same for OS

Intraocular Pressure Measurement n Range: 10 - 22

Anterior chamber depth assessment n Likely shallow if n ≥ 2/3 of nasal iris in shadow

Summary of steps in eye exam n n n Visual Acuity Pupillary examination Visual fields by confrontation Extraocular movements Inspection of lids, conjunctiva and cornea n n Anterior chamber depth Lens clarity Tonometry Fundus examination (Disc, Macula, vessels)

Acute Visual Loss Chapter 2

History n n n n Age POH & PMH Onset Duration Severity of visual loss Monocular vs. binocular Any associated symptoms Examination n n n VA assessment Visual fields Pupillary reactions slit lamp examination Intraocular pressure Ophthalomoscopy - red reflex - clarity of media - direct inspection of the fundus

Media Opacities n Corneal edema: - ground glass appearance - R/O AACG n Corneal abrasion n Hyphema - Traumatic, spontaneous n Vitreous hemorrhage - darkening of red reflex with clear lens, AC and cornea - traumatic - retinal neovascularization

Retinal Diseases Retinal detachment - flashes, floaters, shade over vision - RAPD (if extensive RD) - elevated retina +/- folds n Macular disease - decrease central vision - metamorphopsia n

Central Retinal Artery Occlusion (CRAO) n n n True ophthalmic emergency! Sudden painless and often severe visual loss Permanent damage to the ganglion cells caused by prolonged interruption of retinal arterial blood flow Characteristic “ cherry-red spot ” No optic disc swelling unless there is ophthalmic or carotid artery occlusion Months later, pale disc due to death of ganglion cells and their axons

CRAO Treatment Ocular massage: -To dislodge a small embolus in CRA and restore circulation -Pressing firmly for 10 seconds and then releasing for 10 seconds over a period of ~ 5 minutes n n Ocular hypotensives, vasodilators, paracentesis of anterior chamber n R/O giant cell arteritis in elderly patient without a visible embolus

Branch Retinal Artery Occlusion (BRAO) Sector of the retina is opacified and vision is partially lost n Most often due to embolus n Treat as CRAO n

Central Retinal Vein Occlusion (CRVO) n n n Subacute loss of vision Disc swelling, venous engorgement, cottonwool spots and diffuse retinal hemorrhage. Risk factors: age, HTN, arteriosclerotic vascular disease, conditions that increase blood viscosity (polycythemia vera, sickle cell disease, lymphoma , leukemia) Needs medical evaluation Long term risk for neovascular glaucoma, so periodic ophtho f/u

Optic Nerve Disease Non-Arteritic Ischemic Optic Neuropathy (NAION) - vascular disorder pale, swollen disc +/- splinter hemorrhage loss of VA , VF ( often altitudinal ) n Arteritic Ischemic Optic Neuropathy (AION) Symptoms of giant cell arteritis ESR, CRP, Platelets Rx : systemic steroids n

Optic Nerve Disease Optic neuritis - idiopathic or associated with multiple sclerosis - young adults - decreased visual acuity and colour vision -RAPD -pain with ocular movement -bulbar (disc swelling) or retrobulbar (normal disc) n Traumatic optic neuropathy - direct trauma to optic nerve - indirect : shearing force to the vascular supply n

Visual Pathway Disorders Hemianopia - Causes: vascular or tumors Cortical Blindness - aka central or cerebral - Extensive bilateral damage to cerebral pathways - Normal pupillary reactions and fundi

Chronic Visual Loss Chapter 3

Introduction: n n 1994: 38 million blind people (age >60 yrs) worldwide 1997: in western countries, leading causes of blindness in people over 50 yrs of age 1) 2) 3) 4) Age-Related Macular Degeneration Cataract Glaucoma Diabetes

Glaucoma v Risk factors: Old age African-American race Blood Hypertension Diabetes Mellitus Smoking High IOP Myopia Family History Classification: Open-angle glaucoma vs. angle closure glaucoma Primary vs. secondary

Glaucoma n Evaluation: n n n complete history complete eye examination (including IOP, gonioscopy, optic disc) Perimetry normal Abnormal

Glaucoma v Treatment Options: q Medical: § drops to decrease aqueous secretion or increase aqueous outflow § systemic medications q Laser: § Iridotomy § Iridoplasty § Trabeculoplasty q Surgical: § § q Filtration Surgery (e. g. Trabeculectomy) Tube shunt Cyclodestructive procedures

Cataract § § § congenital vs. acquired often age-related different forms (nuclear, cortical, PSCC) reversible very successful surgery

Cataract n Evaluation: History n Ocular Examination n Others: A-scan, ± B-scan , ± PAM n n Treatment: Surgical n IOL implantation n

Age-Related Macular Degeneration v Types: 1) Dry: 2) Wet: - drusen, RPE changes (atrophy, hyperplasia) - choroidal neovascularization drusen CNV RPE atrophy

Age-Related Macular Degeneration Fluorescein Angiography

Age-Related Macular Degeneration n Treatment: n micronutrient supply n vit C & E, β-carotene, minerals (cupric oxide, zinc oxide) n treat wet ARMD n lasers n intra-vitreal injections of anti-VEGF n surgery n low vision aids

The Red Eye Chapter 4

Diff. Diagnosis: Red Eye n n n n Acute angle closure glaucoma Iritis or iridocyclitis Herpes simplex keratitis Conjunctivitis Episcleritis Soft contact lens associated Scleritis Adnexal Disease Subconjunctival hemorrhage Pterygium Keratoconjunctivitis sicca Abrasions or foreign bodies Corneal ulcer abnormal lid function n THINK n n n Anatomy “front to back” Acute vs. chronic Visually threatening?

History n n n n n Onset? Sudden? Progressive? Constant? Family/friends with red eye? Using meds in eye? Trauma? Recent eye surgery? Contact lens wearer? Recent URTI? Decreased VA? Pain? Discharge? Itching? Photophobia? Eye rubbing? Other symptoms?

Red Eye: Symptoms n n n *Decreased VA (inflamed cornea, iridocyclitis, acute glaucoma) *Pain (keratitis, ulcer, iridocyclitis, acute glaucoma) *Photophobia (iritis) *Colored halos (acute glaucoma) Discharge (conj. or lid inflammation, corneal ulcer) Purulent/mucopurulent: Bacterial n Watery: Viral n Scant, white, stringy: allergy, dry eyes Itching (allergy) n n * can indicate serious ocular disease

Physical Exam n n n Vision Pupil asymmetry or irregularity Inspect: n n n n pattern of redness (heme, injection, ciliary flush) Amount & type of discharge Corneal opacities or irregularities AC shallow? Hypopyon? Hyphema? Fluorescein staining IOP Proptosis? Lid abnormality? Limitation EOM?

Red Eye: Signs n n n *Ciliary flush (corneal inflammation, iridocyclitis, acute glaucoma) Conjuctival hyperemia (nonspecific sign) *Corneal opacification (iritis, corneal edema, acute glaucoma, keratitis, ulcer) n *Corneal epithelial disruption (corneal inflammation, abrasion) *Pupil abnormality (iridocyclitis, acute glaucoma) *Shallow AC (acute angle closure glaucoma) *Elevated IOP (iritis, acute glaucoma) *Proptosis (thyroid disease, orbital or cavernous sinus mass, n Preauricular LN (viral conjunctivitis, Parinaud’s oculoglandular n n infection) syndrome) * can indicate serious ocular disease

Red eye management for care physicians n Blepharitis: n n Stye: n n Will resolve in 10 -14 days Viral conjunctivitis n n Warm compresses (refer if still present after 1 month) Subconj heme: n n Warm compresses, lid care, Abx ointment or oral (if rosacea or Meibomian gland dysfunction) Cool compresses, tears, contact precautions Bacterial conjunctivitis n Cool compresses, antibiotic drop/ointment

Important Side Effects n Topical anesthetics: n Not to be used except for aiding in exam n n Inhibits growth & healing of corneal epithelium Possible severe allergic reaction Decrease blink reflex: exposure to dehydration, injury, infection Topical corticosteroids: n n Can potentiate growth of herpes simplex, fungus Can mask symptoms Cataract formation Elevated IOP

Ocular & Orbital Injuries Chapter 5

Anatomy & Function n Bony orbit n n Globe, EOM, vessels, nerves Rim protective “Blow out” fracture Medial fracture -> sub. Q emphysema of eyelids

Anatomy & Function n Eyelids n Reflex closing when eyes threatened Blinking rewets the cornea Tear drainage n CN VII palsy -> exposure keratopathy n n n Lacrimal apparatus n Tear drainage occurs at medial canthus n Obstruction -> chronic tearing (epiphora)

Anatomy & Function n Conjunctiva & cornea n n Quick reepitheliization post-abrasion Iris & ciliary body Blunt trauma -> pupil margin nick (tear) n Blunt trauma -> hyphema n Blunt trauma -> iritis (pain, redness, photophobia, miosis) n

Anatomy & Function n Lens Cataract n Lens dislocation (ectopia lentis) n n Vitreous humor n n Decreased transparency (hemorrhage, inflammation, infection) Retina Hemorrhage n Macular damage (reduce visual acuity) n

Management or Referral n Chemical burn n Alkali>Acid b/c more rapid penetration OPHTHALMIC EMERGENCY n ALL chemical burns require immediate and perfuse irrigation, THEN ophtho referral n

Urgent Situations n n n n Penetrating injuries of the globe Conjunctival or corneal foreign bodies Hyphema Lid laceration (sutured if not deep and neither the lid margin nor the canaliculi are involved) Traumatic optic neuropathy Radiant energy burns (snow blindness or welder’s burn) Corneal abrasion

Semi-urgent Situation Orbital fracture n Subconjuctival hemorrhage in blunt trauma n Refer patient within 1 -2 days n

Treatment Skills Ocular irrigation n Foreign body removal n Eye meds (cycloplegics, antibiotic ointment, anesthetic drops and ointment) n Patching (pressure patch, shield) n Suturing for simple eyelid skin laceration n

Take-home Points Teardrop-shaped pupil & flat anterior chamber in trauma are associated with perforating injury n Avoid digital palpation of the globe in perforating injury n In chemical burn patient immediate irrigation is crucial as soon as possible n Traumatic abrasions are located in the center or inferior cornea due to Bell’s phenomenon n Know and respect your limits n

Amblyopia & Strabismus Chapter 6

Amblyopia n Definition n n loss of VA not correctable by glasses in otherwise healthy eye 2% in US Strabismic(50%) > refractive > deprivation The brain selects the better image and suppresses the blurred or conflicting image Cortical suppression of sensory input interrupts the normal development of vision

Strabismus n Misalignment of the two eyes Absence of binocular vision n Concomitant: angle of deviation equal in all direction n n n EOM: normal Onset: childhood Rarely caused by neurological disease <6 years Can be due to sensory deprivation Incomitant: angle of deviation varies with direction of gaze n n n EOM : abnormal **Paralytic : CN, MG ** Restrictive: orbital disease, trauma

Strabismus n Phoria: latent deviation n Tropia: manifest deviation

Corneal Light Reflex

Cover Test

Treatment Refractive correction (glasses) n Patching n Surgery n

Neuro-Ophthalmology Chapter 7 **35% of the sensory fibers entering the brain are in the optic nerves and 65% of intracranial disease exhibits neuro-ophthalmic signs or symptoms**

The Neuro-Ophthalmic Exam n n n Visual acuity Confrontation visual fields Pupil size and reaction (Efferent vs Afferent (Marcus Gunn) problem) Ocular motility for strabismus, limitation and nystagmus Fundus exam (optic nerve swelling and venous pulsations)

Parasympathetic

Sympathetic

Efferent vs Afferent defect

Selected Pupillary Disorders n Mydriasis n CN III palsy n n Adie’s Tonic Pupil n n Herniation of temporal lobe or Aneurysm Young women, unilateral, sensitive to dilute pilocarpine, benign Miosis n n Physiologic Horner’s Syndrome n n Etiologic localization (cocaine and hydroxyamphetamine) Argyll Robertson Pupil of tertiary syphilis n small, irregular, reacts to near stimulus only

Selected Motility Disorders n True diplopia is a binocular phenomenon n Etiologies of monocular diplopia? Do not forget to check ALL cranial nerves (especially 5/7/8) n CN IV n n Vertical diplopia, head tilt toward OPPOSITE side Think closed head trauma or small vessel disease Myasthenia Gravis n n n Chronic autoimmune condition affecting skeletal muscle neuromuscular transmission (verify with Tensilon test) Can mimic any nerve palsy and often associated with ptosis NEVER affects pupil

CN III Palsy CN VI Palsy Think: PCOM Aneurysm, Brain Tumor, Trauma Think: Trauma, Elevated ICP, HTN, Diabetes and viral infections

Internuclear Ophthalmoplegia (INO) Think: Elderly-small vessel disease Young Adult-MS

Nystagmus - selected types n n n May be benign or indicate ocular and/or central nervous system disease Definition according to fast phase End-point Nystagmus n n Drug-induced Nystagmus n n Anticonvulsants, Barbiturates/Other sedatives Searching/Pendular Nystagmus n n seen only in extreme positions of eye movement common with congenital severe visual impairment Nystagmus associated with INO

Selected Optic Nerve Disease n Congenital Anomalous Disc Elevation n absence of edema, hemorrhage and presence of SVP n Think: optic disc drusen and hyperopia Papilledema (def? ) n Presence of bil edema, hemorrhage and absence of SVP n Think: hypertension (must check BP) and brain tumor Papillitis/Anterior Optic Neuritis n unil edema, hemorrhage n Think: inflammatory

Selected Optic Nerve Disease n Ischemic Optic Neuropathy Pallor, swelling, hemorrhage n altitudinal visual field loss n n Optic Atrophy n Think: previous optic neuritis or ischemic optic neuropathy, long-standing papilledema, optic nerve compression by a mass lesion, glaucoma

Selected Visual Field Defects

Drugs & The Eye Chapter 8

n Topical Drugs Used for Diagnosis: Fluorescin Dye Fluorescein strip: n water soluble Orange yellow dye Cobalt blue light Eye with corneal ulcer n n Orange becomes green No systemic complications Beware of contact lens staining

Anesthetics n Example: n n n Uses: n n n Propracaine Hydrochloride 0. 5% (Alcaine) Tetracaine 0. 5% Anesthetize cornea within 15 sec, last 10 mins Remove corneal foreign bodies Perform tonometry Examine damaged corneal surface Side effects: n n Allergy: local or systemic Toxic to corneal epithelium ( inhibit mitosis, migration)

Mydriatics (pupil dilation) n Two classes: 1. 2. Cholinergic-blocking ( parasympatholytic) Adrenergic-stimulating (sympathomimetic) Iris sphincter constrict pupil Pupillary dilator muscles

Adrenergic Stimulating Drugs n Phenylephrine 2. 5% or 10% n Dilates in 30 mins, no effect on accommodation n Pupil remains reactive to light n Combine with Tropicamide for maximal dilatation n Infants combine Cyclopentolate 0. 2% & Phenylephrine 1% n Side effects: n acute hypertension or MI (with 10%)