History and Physical EXAMINATION OF THE EYE.pdf

History and Physical EXAMINATION OF THE EYE.pdf

1. EXAMINATION OF THE EYE
History taking & physical
examination

2. Learning objectives
To be able to:
➢Take and understand an ophthalmic history.
➢Examine the function of the eye (acuity and visual field).
➢Test pupillary reactions.
➢Examine eye movements.
➢Examine the structure of the eye.
➢Use the ophthalmoscope.

3. General approach
•Introduce yourself
•Never forget patient name
•Respect patient privacy.
•Try to see things from patient point of view.
•Understand patient mental status, anxiety irritation or depression
•Listening: “Always listen to the patients, they might be telling
you the diagnosis.” Attr. William Osler
•Questioning: simple/clear/avoid medical terms

4. History-taking
“Goals of the history:
1.Identifyingthepatient
2.Obtainingadiagnosis
3.Helpstofocusonexamination
4.Indicateswhenandwhatinvestigationareneeded
5.Selectingtherapy

5. History-taking
•Components of the History
1.Personal details
2.Chief compliant
3.History of present illness
4.Past ocular history
5.Ocular medications
6.General medical & surgical history
7.Systemic medication
8.Social & family history

6. Personal history
•Name: to be familiar with your patient
•Age
Buphthalmosin infant
Keratoconusin teenage
Senile cataract in old age
•Sex
Male as retinitis pigmentosa
Female as autoimmune disease
•Address: to know socioecononicstatus
•Tel no; to keep contact with your patient
•Occupationmetal workers

7. Chief complaints
•Main reason push the pt to seek for visiting an ophthalmic
consultation
•The patient described in their own words
•It should be recorded in his/her own words

8. Analysis of complaints
1.How long?
2.manner of onset
3.Severity
4.Involving one or both eyes?
5.Any associated symptoms?
6.Any similar problems before?

9. Categories of patient complaints
1. Disturbances of vision:
•Blurred or decreased central vision ( distance, near or both)
•Decreased peripheral vision
•Altered image size ( micropsia,macropsia)
•Diplopia ( double vision )
•Floaters( moving lines or specks in field of vision )
•Color vision abnormalities

10. Categories of patient complaints
2. Ocular pain or discomfort:
•Foreign-body sensation
•Ciliary (deep) pain
•Photophobia
•Burning sensation
•Dryness
•Itching
•Eyestrain

11. Categories patient complaints
3. Abnormal ocular secretions:
•Lacrimation
tearing –welling up of tears on ocular surface
•Epiphora
actual spilling of tears over margin of eyelids
onto the face
•Eye discharge
purulent , mucopurulent, mucoid, watery

12. Categories patient complaints
4. Abnormal appearances:
•Ptosis ( drooping of the eyelids )
•Proptosis/exophthalmos (protrusion of the eye )
•Enophthalmos( the opposite of proptosis)
•Misalignment of the eyes
•Redness, other discolorations, opacities, masses

13. Past history
•Medical
Topical medication or same illness before
•Surgical
Any Eye operation done before

14. Past medical history
•DM
•HTN
•Allergy-Eczema
•Drug Co-morbidity

15. Family history
•Certain disease runs in families as:
•Retinitis pigmentosa
•Progressive Myopia
•Glaucoma

16. Examination of the eye
•Components:
1.Testing the vision ( V/A, V/F, color vision )
2.Ocular motility
3.Pupillary examination
4.External & internal examination of the eye
5.Intraocular pressure measurement

17. EXAMINATION OF THE EYE
•Steps in assessing a pt with eye disease
1.Take the patient’s history
2.Test the vision
3.Examine the eyes
4.Special investigations : x-ray, pathology, gram stain, CT scan, MRI

18. Testing the vision
•Human eye is an extremely complex organ, and
Different ways to test the vision.
•3 ways of testing vision used in practice are:
1.Visual acuity-tests if the ptcan see small objects or letters.
2. Visual field--tests the over all area of vision for each eye
3. Color vision–tests if pt. can discriminate b/n different colors.

19. Visual acuity

20. Testing the vision,contd.
Visual Acuity
•Measured with snellen chart
•The pt. stands at 6 m away from the chart , & reads as much as s/he can.
•Each eye must be measured separately.

21. Visual acuity
•Steps:
1.Patientstandsat6mandcovertheleft&testrighteye(OD)first
2.Askthepatienttoreadlettersasmuchashecaninbrightlight
startingfromtoplettersandrecordthelowestlineread
3.Ifthepatientcannotreadthetopletter(6/60),thenaskthepatientto
countfingersheldupinfrontoftheeye.
-humanfingerisaboutthesamesizeastopletterinchart
-Countingfingerat6m(CF6m)=6/60VA
-CFat1mdistance(CF1m)=1/60VA

22. Visual Acuity,contd.
4.If the vision is below CF @ 1m, the patient may still able to detect the
movement of the hand in front of the eye ( HM )
5.If the pt. cannot even see HM ,final test is to shine a light in to the eye ,
and see if s/he can perceive light (LP= light perception ).Record response
as LP or NLP.
6.If LP, test if the patient can identify projection of light in four quadrants of
patient’s vision. Also check for color perception ( Green & Red ).

23. Visual acuity
4.Repeat the same procedure to the left eye ( by covering the right eye)
5.Any patient with defective VA should be tested again through a pinhole
( the pinhole test )
If vision improves with PH →Refractive error => spectacle can correct

24. WHO classification of visual
impairment & blindness
visual acuity classification______
6/6 –6/18 Normal
<6/18 –6/60 visual impairment
<6/60 –3/60 severe v. impairment
<3/60 –NLP Blindness
__________________________________

25. Testing the vision
•The visual Field (VF)
-ItisnotroutinetotesttheVFinallpatients.
-Importantinpts.Suspectedofglaucoma,diseasesofopticnervesorvisual
pathway,andcertainretinaldiseases.
-MethodsofVFtest
1.Theconfrontationtest
-requiresnoequipment,simpletoperform
-onlydetectsseriousVFdefects
-Itworksbycomparingpt’sVFwithexaminer

26. Visual field
2.The Bjerrum screen ( tangent screen )
3. The Goldmann VF test
4. Visual field analzers →computerized

27. Testing the vision,contd.
Color vision
•Tested with special colored charts called ‘Ishihara charts’
•These are used particularly to detect color blindness.

28. Ocular motility examination
Terminology
•Strabismus(squint)–describeamisalignmentoftheeyesinwhichboth
eyesarenotdirectedattheobjectofregard.
•Phoria–isalatenttendencytowardmisalignmentofeyesthatoccuronly
whenbinacularityisinterrupted.
•Tropia–amanifestdeviationthatispresentwhenbotheyesareopen

29. Ocular motility examination,contd,
Positions of gaze:
•Primaryposition(straightahead)
•Secondarypositions(straightup,straightdown,rightgaze,and
leftgaze)
•Tertiarypositions(4obliquepositions:up&right,up&left,down
&right,anddown&left)
•Cardinalpositions(up&right,up&left,right,left,down&right,
down&left)
•Midlinepositions(straightup&downfromprimaryposition)

30. Ocular motility
examination,contd,
•Actions of EOMs

31. Ocular motility examination,cont
•Typesofhetrophoriaandhetrotropia
prefix nameofdisorder description
-phoria(latent)-tropia(manifest)
Eso- esophoria esotropia inwarddeviation
Exo- exophoria exotropia outwarddeviation
Hyper-hyperphoriahypertropia upwarddeviation
Hypo-hypophoriahypotropia downwarddeviation

32. Pupillary examination
•It can give a great deal of information & is one of the most
important parts of eye exam.
•The pupil reactions:
1.The light reflex-in which pupil reacts( constricts) when light is
shone in the eye.
A. Direct light reflex
B. Consensual light reflex
2. The accommodation or near reflex →in which the pupil constricts
when the eye looks at near objects.

33. •The reflex is divided into two parts:
1. The afferent part: From retina to mid brain
2. The efferent part: from mid brain along oculomotor nerve to pupil
constrictor musle
▪In normal person both pupils are always same size as each other and both
always react in the same way as each other.
▪If pupils are not reacting normally the defect may be in the afferent or
efferent part of reflex.
▪A defect in the efferent part( something wrong with oculomotor n, or
sphincter m.)will nearly always cause affected pupil to be dilated.
▪An afferent pupil defect is a sign of optic nerve disease or extensive retinal
disease.

34. External & Internal examination of
eye
•Orbit
•Eyelids
•Lacrimal apparatus
•Conjunctiva
•Cornea
•Anterior chamber
•Iris
•Lens
•Vitreous humor
•Retina
•Funduscopy
( Ophthalmoscope)

35. •Direct ophthalmoscope
-an instrument used to see the fundus ( back of the eye -retina)

36. Intraocular pressure (IOP)
•The IOP should be measured in any patient with suspected glaucoma.
•The risk of glaucoma increases in middle age ,and so IOP should be
measured routinely in any one above 40.
•3 methods of measuring IOP( tonometry ) are:
1.Digital tonometry
»very simple but not at all accurate
2.The schiotz tonometer
»Cheap & fairly accurate if used correctly
3.The applanation tonometer
»Expensive & much more accurate

37. Thank you !