Lecture Outline. Ge(ng the Most Out of Your Ocular Exam. Medical History. From a distance 7/8/17
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1 Lecture Outline Ge(ng the Most Out of Your Ocular Exam Kimberly Hsu, DVM, MSc, DACVO Eye Care for Animals St. Charles, IL (630) Medical History Distance Exam Assessing Vision Neuro-Ophthalmology Exam Schirmer Tear Test (STT) Intraocular Pressure (IOP) Fluorescein Stain RetroilluminaYon Eyelids Nasolacrimal System Third Eyelid ConjuncYva and Sclera Cornea Anterior Chamber Iris and Pupil Lens Vitreous & Fundic Exam Medical History Time of onset and progression? Recurrent? Discomfort or pain? Ocular discharge? Change in appearance or color? Concurrent systemic health? Uni vs. bilateral? Vision in light? Vision in dark? From a distance Behavior/mentaYon/navigaYon Facial symmetry (ears, eyelids, lips) Eyelid posiyon; palpebral fissure size Ocular and nasal discharge Corneal clarity and reflecyvity (tear film) Purkinje images brisk or dull/irregular? Globe size and posiyon Look from above Globe color Orbital palpayon and globe retropulsion 1
2 Assessing Vision Distance exam Maze test bright/dim light Pylons or trap the dog in the corner using common items in room (ie. garbage can, chair, etc.) Cogon ball test Neuro-ophthalmic Exam Neuro-Ophthalmology made simple! Test Nerves Tested Tips Palpebral Reflex (Medial/lateral canthus touch to elicit blink) Menace Response (Menacing hand gesture to elicit blink/ withdrawal) Dazzle Reflex (Bright light to elicit blink) Pupillary Light Reflex (Light causes pupillary constricyon) Oculocephalic ( Doll s eye ) CN5 (sensory) CN7 Re#na, CN2 Cerebellum, Cortex CN7 Re#na, CN2 CN7 Re#na, CN2 CN3 CN8, CN3, CN4, CN6 If absent, touch the face, nasal planum, etc. to confirm Avoid air flow, symulayng vibrissae; blink or avoidance considered + Use a bright light! Indirect PLR helpful if iris not easy to see (ie. hyphema, etc.) Schirmer Tear Test Do this first! Bogom eyelid, lateral 1/3 rd Normal is 15-25mm/min Varies with conformayon Brachycephalic dogs need more tears (>18-20mm/ min) If borderline, look for signs of kerayys, history of conjuncyviys, etc. Measuring Intraocular Pressure (IOP) Factors that can elevate IOP Dorsoventral eyelid manipulayon Lateral eyelid manipulayon Brachycephalic dogs especially sensiyve to changes in eyelid posiyon Pressure on jugular veins, Yght neck collars Agempted eyelid closure Proparacaine if ocular surface pain Excitement Thickened or abnormal corneas (ie. corneal edema) 2
3 Does the IOP fit your payent?! Normal 15-25mmHg IOP decreases with age <10mmHg is oqen seen in older dogs Glaucoma >25mmHg (usually in 40s and 50s) UveiYs (usually <10mmHg) Early glaucoma should be suspected if IOP is normal with moderate to severe uveiys! The many uses of fluorescein stain! DetecYng corneal ulcers Hydrophilic corneal stroma stains + Lipophilic Descemet s membrane does not stain! Tear Film Break Up Time (tear film quality or evaporayon) Apply 2-3 drops of fluorescein Open the eyelids and watch for dark spot to form Normal is >20s Most qualitayve KCS dogs have TFBUT of <10s Seidel Test (aqueous humor leakage with corneal rupture) Jone s Test (nasolacrimal patency) Light and magnificayon are your friends! Dark and dim light STT - do 1 st! Neuro-ophthalmic exam before dilayon Do not dilate unless IOP is normal Minimize handling of the eye with deep corneal ulcers Materials to Gather Focal light source (ie. Finoff transilluminator) Magnifying Loupes (ie. OpYvisor) Direct ophthalmoscope Indirect lens (28D, 20D) Schirmer Tear Test Fluorescein Stain Tropicamide Proparacaine Sterile eye wash Cogon Yp applicators RetroilluminaYon Pupil size, shape and symmetry ObstrucYons in normally transparent structures obscure the fundic reflex Cornea, aqueous humor, lens, vitreous Oqen helps to see subtle cataracts, corneal blood vessels, etc. Nuclear sclerosis (centered symmetrical circular relucency) vs. cataract (irregular, oqen more obstrucyve) 3
4 Eyelids Periocular discharge Perform STT if increased mucous DermaYYs or blephariys Localized or diffuse Palpebral fissure size and shape Eyelid posiyon Entropion/ectropion, eyelid laxity Proparacaine to differenyate spasyc vs. anatomical entropion Abnormal hairs DisYchiae, ectopic cilia, trichiasis Corneal lesions oqen correspond to the locayon of abnormaliyes Meibomian glands Masses InflammaYon, etc. Nasolacrimal System Nasolacrimal system largely encased in bone Check for tear staining of medial canthus Purulent discharge, swelling near medial canthus (indicator for dacryocyyys) Look for occlusion, narrowing or absence of nasolacrimal puncta Jone s test Useful in non-brachycephalic dogs only! Highly variable mesocephalic dogs up to 14 minutes Brachycephalic dogs oqen >30 minutes or no passage Nasolacrimal flush If nasolacrimal obstrucyon is suspected NL flush: 24G catheter, 3cc syringe with eye wash, fluorescein Third Eyelid (TEL) ConjuncYva and Sclera Examine at rest then gently retropulse globe through upper lid to elevate TEL Omit retropulsion if risk of globe rupture Examine posterior surface using fixayon forceps Prolapsed gland of the TEL (Cherry Eye) Check carylage too NeoplasYc masses IrregulariYes: follicular conjuncyviys, plasmoma, trauma Foreign bodies Changes in color: depigmentayon, hyperemia, etc. TEL posiyon changes with globe posiyon! Conjunc6va Change in color Hyperemia most common Chemosis Surface irregulariyes Discharge, increased surface moisture vs. dryness SubconjuncYval hemorrhage or emphysema Sclera Changes in contour or thickness Changes in scleral show Changes in color 4
5 ConjuncYval vs. Episcleral Blood Vessels Bulbar conjuncyva (thin light vessels) overlies the sclera/episclera (thick dark straight vessels) ConjuncYval hyperemia surface epithelial disease vs. episcleral hyperemia intraocular disease Cornea Change in color, loss in transparency Changes in contour Corneal ulcers superficial, indolent, stromal, descemetoceles Indolent: loose edges wicking of FLST, touch with a Q-Yp! Descemetoceles don t take up stain! Surface irregulariyes Changes in diameter Measure diameter in mm (STT strips work well) to compare Anterior Chamber Anterior chamber depth and symmetry Look from the side Anterior chamber clarity Aqueous flare? Hyphema? Hypopyon? Fibrin clots? Pigmented cysts? Hypopyon is usually ventral so look down (under lower eyelid) Slit beam Loss of iris detail Iris and Pupil Changes to iris color and texture Iridal hyperpigmentayon, rubeosis iridis, masses, etc. Altered pupil shape or posiyon Iris atrophy, synechiae, etc. Altered pupil size Miosis (ie. uveiys, Horner s Syndrome), mydriasis (ie. reynal detachment, glaucoma) Altered pupil color Cataract, vitriys, etc. 5
6 Lens Fundic exam Use of Purkinje images and retrolluminayon Lens opacity Altered size Flat, resorbing lens: hypermature cataract Intumescent with shallow chamber: diabeyc cataract, rapid onset juvenile cataract Altered shape Anterior surface smooth vs. irregular (hyper? Altered posiyon Anterior chamber depth Aphakic crescent Grading cataracts Incipient (Punctate) Immature (Tapetal reflex syll visible) Mature (Tapetal reflex obscured) Hypermature (Wrinkled, Liquifying) Morganian (Liquefied) Dilate! Indirect ophthalmoscopy greatest field of view 1. Find the reflex at arm s length 2. Insert your lens (28D or 20D), move lens in and out unyl opyc nerve in focus 3. Maintain alignment 4. If you lose the image, repeat! Direct ophthalmoscopy (set to 0D, same eye as payent s) 1. Find the reflex > 2-3cm SystemaYc exam Nerve Blood vessels Tapetal and Non-tapetal fundus Quadrants PracYce!!! Huge individual variayon Fundic Exam Recommended ocular exams Re6na Change in color Changes in tapetal reflecyvity Changes in vasculature diameter, color, etc. ElevaYon or detachment Op6c Nerve Change in size Color All diabeyc dogs 80% will get a cataract At higher risk for KCS All brachycephalic dogs check tear film, corneal pigment, etc. Breeds at risk for ocular disease Golden Retrievers for Pigmentary UveiYs Iridal hyperpigmentayon, cataract,uveal cysts, etc. Cairn Terriers for Ocular Melanosis Scleral pigment, iridal hyperpigmentayon etc. All hypertensive cats Vitreal and reynal hemorrahage = end organ damage 6
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