Documentation of the Ocular Exam

Documentation of the Ocular Exam Nicholas Testa, MD. Associate Medical Director LAC+USC Medical Center., Assistant Clinical Professor of Emergency Medicine testa((ousc.edu Documenting an ocular exam is a unique art that if done in a consistent fashion can guide the practitioner while assuring that all data is accurately and rapidly recorded in the medieal record. This lecture reviews the techniques that Ophthalmologists utilize to document the eye exam. Understanding how Ophthalmologists document will assist the Emergency Physician in interpreting consults while also providing an accepted approach for the EP to document his exam. We will also review some of the basic procedures that should be done on every patient with a visual complaint and discuss how to get the most accurate data. Performing a Visual Acuity Examination ]) Place the chart at 20 feet (or 6 meters) from the patient 2) Ifthe patient uses glasses then the test is performed with them on 3) The first evaluated eye is the one that is believed to see less 4) On the Snellen chart a line is considered readable when the patient can correctly identify 50% of the line plus 2 (i.e. in a row of 10 characters the patient must get 7 coltect) 5) Ifthe measurement is reduced (below 20/20) then the test should be repeated with pinholes (pinholes are not to be used with glasses) 6) Ifthe patient cannot see any of the characters then they should be asked to count fingers at 4 feet and then at one-foot intervals until the patient can see 7) Ifthe patient cannot count fingers they should be tested for the ability to see motion. 8) If they cannot see motion they should be evaluated for the ability to see light E 1 F P Z T 0 Z 3 LPED 4 PEer]} 5 I:J)rczP 6 rclopzii 7 I'> 1: r, 0 T 1: C 8 - ~ 10 11 201200 K 0 N V C S R Z H 0 20/100 OHSCV 20{70 OZNRK 00 CRKOZ 70/50 N6HOV 20{40 rtnof(fwf 20/30 vcezo QHNVK 20{2' zoo lill'! '1;11''' If. 20/20 o '\JIY 0 ::;l: Snellen Chart Baily-Lovie Chart Landholt Rings Documentation of the Eye Exam in the Emergency Department Visual Acuity (V A) Visual Fields (VF) Extra Ocular Movements (EOM) Lids Lashes Lacrimal (LLL) Conjunctiva and Sclera (CIS) Cornea (K) Anterior Chamber (AC) Iris (I) Lens(L) Retina (R) Intra Ocular Pressure (lop) OS 20/20 wi PH Jntact by 4 Intact wlo diplopia No lesions White and Quiet No Fluorescein Uptake Deep and Quiet Round and Reactive Clear Sharp disc margins 20(tiJ, 5% OD 20/20 wi PH intact by 4 Intact wlo diplopia No Lesion White and Quiet No Fluorescein Uptake Deep and Quiet Round and Reactive Clear Sharp disc margins 20@5% ----------------------

Common Ophthamologic Abbreviations AC Anterior Chamber ACG Angle Closure Glaucoma AMD Age-Related Macular Degeneration APD Afferent Pupillary Defect Cor K Cornea COAG Chronic Open Angle Glaucoma Conj Conjunctiva CRAO Central Retinal Artery Occlusion CRVO Central Retinal Vein Occlusion D Disc D,M,V,P Disc, Macula, Vessels and Periphery E.E External Exam F&C Flare and Cells FC Finger Counting I Iris 1.0. Inferior Oblique I.R. Inferior Rectus lop Intraocular Pressure L Lens L.P. Light Perception L.R. Lateral Rectus LLL Left Lower Lid or Lid Lash Lacrimal LUL Left Upper Lid M Macula M.R. Medial Rectus NT NLP O.D. O.S. O.U. P ph RD RLL RUL S.L.E. S.O. S.R. V V.F. VA No Improvement No Light Perception Right Eye Left Eye Both Eyes Peripheral Pin Hole Retinal Detachment Right Lower Lid Right Upper Lid Slit Lamp Exam Superior Oblique Superior Rectus Vitreous Visual Field Visual Acuity The following table compares what it means to have 20120 visual acuity compared to having any other visual acuity. For example a person with 20/20 vision sees at 30 feet what a person with 20115 vision can see at 40 fee1. Visual Acuity Distance From Object 20/10 60 feet 20115 40 feet 20/20 ("norma)" vision) 30 feet 20/25 24 feet 20/30 20 feet 20/40 15 feet 20/50 12 feet 20/60 10 feet 20/80 7 feet 201100 6 feet 201200 3 feet 20/400 ] feet Intraocular Pressure Measurements 1) Applanation (Goldmann) tonometry uses a small probe to gently flatten part ofthe cornea to measure eye pressure. The pressure in the eye is measured by how much force is needed to flatten the cornea. This type of tonometry is very accurate and is often used to measure lop after a simple screening test (such as air-pufttonometry) finds an increased lop. 2) Electronic indentation tonometry is now used most often to check for increased lop. This is typically referred to as the tono-pen. 3) Noncontact tonometry (pneumotonometry or air-pufftonometry) does not touch the eye but uses a puff of air to flatten the cornea. This type of tonometry is not the most sensitive way to measure intraocular pressure. 4) Indentation (Schiotz) tonometry uses a plunger to gently push the cornea. The pressure in the eye is measured by how much weight is needed to flatten the cornea.

The Traumatic Eye: A Simplified Approach Nicholas Testa, M.D. Associate Medical Director, LAC+USC Assistant Clinical Professor of Emergency Medicine fesfa(ij),usc. edu Over 50% of all eye trauma patients will initially present to the Emergency Department so it is vital that the Emergency Physician (EP) is well versed in the management of eye trauma. Every EP will have their own approach to the eye exam, but when discussing these cases with a consultant it is important to understand the accepted standard approach that the Ophthalmologists utilize to asses eye trauma. Eye Trauma Classification* 1) Open or closed globe injury 2) Visual acuity 3) Afferent pupillary defect 4) Area of injury (Cornea, Exposed sclera or Posterior to the lid margins) *Pieramici D. el al.. "A System for ClassifYing Mechanicallniuries of the Eye ", American Journal of Ophthalmology, June 1997; 123:820-831 Globe Rupture Any disruption of the globe is vision threatening and requires emergent repair. In many cases the diagnosis is obvious, but it is the more subtle occult disruptions that pose the greatest challenge to the EP. Signs of an Occult Globe Rupture 1) Seidel's sign Streaming and clearing of fluorescein away from the injury 2) Peaked pupil Teardrop shaped pupil resulting from movement ofthe iris to patch the leaking sclera 3) Bloody chemosis Bulging of the conjunctiva 4) Hyphema Blood in the anterior chamber 5) Scleral smudge Disruption of the sclera revealing the choroid below 6) Hypotonia * * Low intraocular pressure **While if is nol recommended 10 check intraocular pressure Vthere is ri... kfor globe disruption il has been shown to be one ofihe mosl sensitive signs. ~lon routine exam the c1inicianfinds an lop ofless than 5mmHg, an occult open globe should be suspected.

Eye Lid Lacerations When do you need the specialist? ]) Laceration through the lid margins that may result in entropion or extropion 2) Deep lacerations through the upper lid that may result in ptosis 3) Any injury ofthe medial!/3 of the lid margin suggesting damage to the lacrimal system Hyphema A hyphema is a collection of blood in the anterior chamber of the eye that results from trauma to one of the vessels in the iris. While a small hyphema does not pose any serious risk initially, over time the patient is at increased risk for staining the cornea, acute angle closure glaucoma from the red cells blocking the canal of Schlemm, or rcbleed which most frequently occurs 3-5 days after the initial injury. Grades of Hyphema Q Grade 1+: less than 1/3 of the anterior chamber <it> Grade 2+: 1/3 to 1,1;, ofthe anterior chamber <W> Grade 3+: greater than 1,1;, of the anterior chamber Grade 4+: "8-ball" hyphema The management of hyphema has changed over time and it is now acceptable to send these patients home as long as they meet the fonowing criteria: 1) Compliant adults and children 2) 24 hour follow-up 3) No history of bleeding disorders 4) Less then a grade 2+ hyphema (see grading chart) 5) Normal intraocular pressures Outpatient Recommendations for Hyphema ]) Stop all anticoagulation therapy 2) Eye rest (i.e. no reading, television or computer use) 3) Hard eye shield 4) Sedation, pain control and antiemetics (no NSAID's) 5) Short acting cycloplegics and topical steroids 6) Sleep sitting up - so blood pools at inferior aspect of anterior chamber 7) 24 hour ophthalmology follow-up

Traumatic Iritis Traumatic iritis presents very much like other types of anterior uveitides, however a history of trauma is critical in making a correct diagnosis. There tends to be photophobia in both the involved and the uninvolved eye (because of consensual pupillary constriction), perilimic injection, and cells and flare in the anterior chamber. Treatment consists primarily of a cycloplegic agent. Topical steroids are usually not necessary because the stimulus for the iritis, that is the trauma itself, is no longer present. However, topical steroids can be helpful for refractory cases or when the patient is in pain. Afferent Pupillury Defect (AI)D) An afferent pupillary defect is identified by examining the eyes with a bright light. In normal circumstances, when a light is shone in one eye, both pupils constrict. However, when a light is shone in the abnormal eye of a patient with an APD, the pupil of the affected eye paradoxically dilates rather than constricts. This abnormal response signifies the brain is not receiving the message properly suggesting that there is injury to either the optic nerve or retina. Differential Diagnosis for APD in Trauma 1) Retinal detachment 2) Retrobulbar hemorrhage 3) Traumatic optic neuropathy 4) Head injury Normal Response Left Eye Injured (@)

Traumatic Retinal Detachment Retinal detachment occurs when the multilayer neurosensory retina separates from the underlying retinal pigment epithelium and choroid. In the case of trauma the detachment occurs actively due to vitreous traction on the retina. Any separation between the neurosensory retina and the underlying choroidal circulation results in a highly ischemic state and rapid and progressive photoreceptor degeneration. The amount of photoreceptor degeneration and Joss of vision can be minimized by rapid diagnosis and treatment. Without treatment, most symptomatic retina] detachments progress to involve the entire retina and lead to loss of vision. Traumatic Retina] Detachment as Seen on Ultrasound Blaivas M, Theodora D, Sierzenski P "A Study (?f Bed,ide Or.:ular Ultrasound in the Emergency Department", Acad Emerg ivied Augllsl2DD2, Vol 9, No.8 Retrobulbar Hemorrhage A sudden accumulation of blood behind the eye in the setting of trauma is known as a retrobulbar hemorrhage. This hemorrhage increases the pressure behind the eye and in turn causes a sudden increase in intraocular pressure as well as central retinal artery ischemia. If the increase in pressure is not treated early it can result in permanent loss of vision in the affected eye. Animal models have shown that central retinal artery ischemia is reversible up to 100 minutes after the time of injury, so it is imperative that the physician recognize the following constejjation of findings associated with a traumatic, vision threatening, retrobulbar hemorrhage and intervene accordingly with a lateral canthotomy and cantho]ysis. Rot/obulbar t1emorrhage >.,'1 I.., (. ) i'

Indications for Lateral Canthotomy Primary indications Decreased visual acuity Proptosis lop greater then 45mmHG Secondary indications Eye pain Afferent pupillary defect Ophthalmoplegia Cherry red macula Nerve head pallor Acid/Alkali Burns to the Chemical burns to the eye can be a devastating injury that requires prompt attention by the EP. When these patients present to the ED all other interventions should be delayed until aggressive irrigation can be initiated with normal saline or tap water and Morgan lenses. The goal is to irrigate the eyes to a ph of about 7.5, or if only one eye is affected, to get the ph in that eye to match the ph in the unaffected eye. If a chemical burn to the eye results in significant ischemia to the limbus and cornea the likelihood of a significant recovery is low as the cornea can no longer regenerate. The Ophthalmologists use the Roper-Hall classification to asses the severity of chemical burns and it is to the advantage of the EP to understand this classification when discussing the disposition and management of these cases with the Ophthalmologist. Rober-Hall Classification of Chemical Exposures to the Eye Grade Prognosis Lim bal Ischemia Corneal Involvement Grade I Good None Epithelial Damage Grade II Good Less than 1/3 Haze but the iris detail is visible Grade III Guarded 1/3 to Total epithelial haze that obscures the iris Grade IV Poor Greater than Cornea is opaque with the iris and pupil obscured

Clinical Pearls for the Red Eye 1. The painful red eye is generally the first indicator of vision threatening pathology while the painless red eye is less concerning. 2. The clinician must be able to differentiate between ciliary and conjunctival injection. Ciliary injection indicates inflammation of the cornea. iris, or ciliary body, whereas conjunctival injection mainly affects the posterior conjunctival blood vessels. 3. The biggest pitfalls in the diagnosis of acute angle closure glaucoma is not entertaining the diagnosis because the patient presents as a headache. 4. About 88% of all cases of bacterial keratitis will be preceded by either ocular surgery. contact lenses. topical steroids or ocular trauma. 5. Hutchison sign is the presence oflesion on the tip of the nose in a patient with Herpes Zoster of the trigeminal nerve. If this sign is present there is a 75% chance there will be corneal involvement. 6. Iritis can have multiple etiologies such as trauma, infections and autoimmunity. 7. Endophthalmitis is a deep infection of the vitreous of the eye and can be caused by exogenous causes (i.e. penetrating eye injury) or endogenous causes (i.e. hematogenous spread in bacterial endocarditis). 8. While conjunctivitis and episcleritis will briskly respond to phenylephrine drops scleritis will not respond. 9. While scleritis does not usually present an immediate threat it does increase the risk of globe rupture so the clinician must provide a hard eye shield for all suspected scleritis cases. 10 Orbital cellulitis is more common in chi1dren and associated with chemosis, decreased vision, elevated pressures and pain with eye movement.