Basic ophthalmological examination in OPD

Basics of eye examination to guide the ones starting off with their ophthalmology residency.

1. BASIC EXAMINATION OF EYES IN OPD Dr. Vaishali Rakheja Senior Resident Dr. R. P. Centre for Ophthalmic Sciences AIIMS, New Delhi

2. History taking Vision assessment Torch light examination Slit lamp evaluation Fundus evaluation

3. Leading Questions U/L or B/L Onset – Sudden/insidious Progression of complaints Painful/ painless Associated systemic history Sudden and painless diminution of vision Retinal detachments Retinal vein occlusions Vitreous hemorrhage Lens subluxation or dislocation Posterior uveitis Sudden and painful diminution of vision Acute anterior uveitis Keratitis Acute angle closure glaucoma Retrobulbar neuritis Endophthalmitis Traumatic lacerations Gradual, painless, progressive diminution of vision Refractive errors, Presbyopia Cataract POAG, JOAG Corneal dystrophy Drug induced optic neuropathy Hereditary macular degenerations

4. EXAMINATION

5. Visual Acuity Spatial limits of visual discrimination. Reciprocal of minimal angle resolvable.

6. Visual Acuity SNELLEN’S CHART LogMAR CHART LANDOLT’S C-CHART

7. Refraction Objective refraction AR Retinoscopy Subjective refraction (assessing patient’s response) Cycloplegic refraction

8. Visual field assessment in OPD Confrontation test Each quadrant is tested monoocularly Patient is made to count fingers or identify a light source For the right eye of the patient – left hand of the examiner with right eye occluded. Interpretation: if the fingers/ light source identified simultaneously- normal fields

9. Torch light examination General inspection Globe position Ocular motility Strabismus: Hirschberg’s test Pupil Eyelids and adnexa

10. General inspection Face- look for any asymmetry Extra-ocular features Scars suggestive of trauma or surgery

11. Globe Deep set globe Enophthalmos Proptosis, dystopia

12. Ocular motility 6 cardinal gazes are tested Any limitation indicated with a minus sign Overaction indicated with a plus sign

13. Hirschberg’s test Malalignment of visual axis – strabismus The corneal reflex shifted opposite to the direction of deviation 15 degrees- at the pupillary border 30 degrees- between pupillary border and limbus 45 degrees- at the limbus

14. Pupil An aperture in the center of the iris Size of the pupil is determined by integrity of the afferent and efferent pupillary pathways and the tone of the sphincter and dilator pupillae muscles. Anisocoria - difference more than 0.5 mm. Polycoria - more than one pupillary openings. Corectopia - ectopic pupil Pupillary reflex – direct and consensual Relative afferent pupillary defect – Swinging Flash light test

15. Swinging flash light test for eliciting RAPD

16. Eyelids and adnexa The upper eyelid covers approx. 2mm of the cornea and the lower eyelid lies just apposed to the lower limbus Ptosis Lid retraction Entropion and ectropion Eyelashes Lacrimal drainage system

17. Lacrimal drainage system

18. Slit lamp examination

19. Conjunctiva and sclera Anatomical divisions- Marginal, palpebral, forniceal , bulbar Discoloration- melanosis Congestion- Diffuse, circumcorneal Papillae and follicles Degenerations like pterygium, pingecula , and in vit A deficiency bitot spots in bulbar conjunctiva Trauma- conjunctival lacerations, subconjunctival hemorrhage

20. Cornea Size – microcornea(<10mm) , megalocornea (>13 mm) Shape – keratoconus, keratoglobus Opacities – nebular, macular, leucomatous Neovascularisation – deep and superficial Sensation Fluorescein staining – abrasion, epithelial defects, ulceration Trauma- lacerations, foreign body

21. Anterior Chamber Depth- Van Herick grading Contents- optically clear/ flare Aq cells Aq pigments Hypopyon Hyphaema

22. Iris Color Pattern - atrophy Defects - coloboma

23. Lens Position Transparency

24. IOP Contact and non contact procedure Applanation and indentation tonometer Gold standard- Goldman applanation tonometry- but contact procedures being avoided- COVID-19

25. Fundus evaluation DDO Direct ophthalmoscopy Indirect ophthalmoscopy 90 D slit lamp biomicroscopy

26. Thank you