OPHTHALMIC ASSESSMENT Nehal MANDOUR Associate Specialist Urgent Care Lead Clinician REI - PLYMOUTH
Patients presenting with an eye complaint may strike fear in some practitioner's hearts as they recall student days standing in dimly lit rooms looking at incomprehensible machines which obscure both patient and doctor, wondering what on earth was going on.
OUTLINE Anatomy overview Instruments used for eye exam History taking important?! Assessment of Eye Functions Assessment of Eye Structures
General appearance The eye is one of the few organs of the body which can be looked at both outside and in and whose basic function can be assessed using simple desk-top tools.
Cross section appearance
EYE ASSESSMENT
Good History Taking is Essential Complaint History of present complaint Past ocular history Medical history Drug history Family history Allergy
Is History Taking REALLY Important? http://www.youtube.com/watch?v=zkjcbqua B4E
History of Present Complaint Patient initial report of condition Which Eye Right Vision Left Vision Pain (sharp, fb sensation, ache, throbbing, pressure, headache) Duration Lid abnormality (lump,droop, oedema) Duration Analgesia taken? Trauma (high velocity, organic, power tool, chemical) When Change in Vision: (Please circle.) Duration Blur: all over, central Peripheral shadow (where)... Distortion Onset: sudden days, weeks, months Intermittent, Persistent Progression: stable, getting worse Associated pain headache Discharge (sticky, watery) Duration Floaters (how many) Duration Flashes (day, night) Duration Redness(where, how did you notice it) Duration Diplopia (vertical, horizontal, both eyes, one eye) Duration Associated with headache? Photophobia Duration GP ref for GCA (only if vision affected or diplopia- assess as above) ESR... Requested? CRP... Requested?
Previous Ocular History: Glasses wear ( distance,near), Contact lens wear Previous eye condition / treatment Previous ocular trauma or surgery Level of Visual Acuity in involved eye before injury Level of vision in the other eye. Medical History: Routine + Use of anticoagulant medications ---- especially over-the-counter medications containing aspirin Status of tetanus prophylaxis Any difficulties with previous anaesthesia or surgery
Instruments used for Eye Examination
In General Practice VA Chart Pen torch +/- blue filter Magnifying lens Slit lamp(?) Hand-held direct Ophthalmoscope Drops: Fluorescein drop / fluorescein impregnated paper Topical anaesthesia Topical short acting mydriatics preferably G.Tropicamide Ruler
EYE EXAMINATION Visual Acuity Pupil Reflexes Visual Field EOM Pressure Anterior segment: Lid /Lacrimal system Conjunctiva /Sclera Cornea Anterior Chamber Iris / Pupil Lens Orbit ( If you can get that far GREAT ) Posterior examination Red Reflex Fundus exam Vitreous/Disc/Retina/Macula
Examining Eye Function
1.Visual Acuity First step (EXCEPT in CHEMICAL INJURY) Prior to shining light or manipulating the eye. Injured eye and uninjured eye Best corrected (ideal)-i.e. with correct glasses Pinhole: important ( reduction in vision with the pinhole can be a sign of ophthalmic pathology rather than a refractive error ) Pain relief, Tissue paper, Blinking, Guessing!
Each eye is tested independently. "Best corrected vision." Ask patients to read smallest line they can see. Repeat with the other eye.
Recording Visual acuity Rt eye and Lt eye Unaided vs with glasses With pin hole ( Improvement vs no improvement) 6/6 6/60 (+ or -) Counting fingers : CF @. Meters Hand movement : HM Light perception: LP No light perception : NPL ( Do not write: BLIND or UNABLE TO SEE)
2. Pupillary Light Reflexes Darkened room Ask the patient to fix on a distant object (to avoid the accommodation reflex that causes constriction of the pupil). Shine bright a pen torch into one eye and assess if the pupil constricts. Then repeat this in the other eye. Observe for the : Direct response (constriction of the same pupil) Consensual response (simultaneous constriction of other pupil)
NORMAL
Swinging Flashlight" Test If it dilates rather than constricts, this is known as an RAPD. A positive finding is a strong indicator of retinal or optic nerve pathology. Ask the patient to fixate on an object in the distance, and then direct a bright light to one eye. Move the light quickly to the other eye and repeat the process, swinging the light from eye to eye. A normal reaction would be a brisk pupil constriction of the stimulated eye; as the light is moved to the fellow eye it should constrict (or stay constricted).
RAPD
3.a.Peripheral Visual Field Assessment Sit at the same horizontal and vertical level as patient, 1 meter away Ask patient to close one eye and you close your eye facing it Ask patient continue looking at your eye without moving eyes while you hold up your fingers and ask patient How many fingers you can see? in each quadrant. Repeat with your other eye. Assessing Right Eye Assessing Left Eye
3.b. Central Visual Field Look at my face (Is any part missing or blurred?) Amsler chart
4. Ocular Movements / Alignment Corneal Reflex Extra ocular movement in all directions of gaze Accommodation
Ocular Motility a. Corneal Reflex Use pen torch to create a light reflex on cornea. Normal corneal reflex should fall in the same position in each eye Misalignment: Esotropia: Convergent squint Exotropia: Divergent Squint Hypertopia: one eye is higher than the other Hypotropia: one eye is lower than other
Extra ocular Muscle movement in all directions of gaze Each of the 6 positions of gaze isolate the action of each of EOM SO '4', LR '6', all the rest '3'
Ocular Motility c. Accommodation The room light should be turned on. Ask patient to gaze to a far wall. Tell them that as soon as they see the your finger /pen/other object, they should focus straight on it. Bring your finger directly in towards the patient's nose. This will cause : the patient to look cross-eyed and the pupils should constrict briskly (Failure to do so is known as light-near dissociation.)
EYE STRUCTURE Assessment Anatomical examination Work systematically from front to back.
Lid/Lacrimal Haematoma / Swelling/ Signs of infection Wounds : Lacerations ( full or partial thickness ) esp. to margin / lacrimal puncti or canaliculi /Puncture wounds FB Position: Ptosis ( drooping)/ Retraction Ectropion / Entropion Lagophthalmos (inability to close eye fully ) Lumps and bumps (cysts, warts, chalazion, BCCs, SCCs) Skin rash / ulceration Lashes ( maldirected-rubbing) Margin (inflammation- Blephritis)
Lid Haematoma (Black Eye) The most common type of blunt eye injury Usually innocent ALWAYS exclude more serious conditions: Associated globe or orbit trauma: examine the integrity of globe before lids become oedematous Anterior fossa fracture: assoc. subconj. hge without a posterior limit Basal skull fracture: characteristic bilateral ring haematoma= panda eyes)
Eyelid lacerations REFER Deeper lacerations, Involving the lid margin Involving lacrimal punctum/canliculus Any associated tissue loss
Allergic lid oedema Ectropion Entropion Rubbing lashes
Ptosis Assessment
Lagophthalmos (ask patient to tightly squeeze eye lids) Lid retraction (visible sclera above the superior limbus+/- below inferior limbus)
Lumps and Bumps
Lacrimal sac Inflammation ( Dacryocystitis) Acute Chronic +ve regurge NOT Lactimal
Orbit Look Listen Feel
Look Bruises Chemosis of conjunctiva Lid swellings/ haematoma /emphysema Nose bleeds Check the EOMs Proptosis (exophthalmos) Enophthalmos
Proptosis or Enophthalmos: Direction Severity: Look plastic ruler resting on lateral canthus Ideally in both erect and supine positions Proptosis : Readings > 20mm Difference of 2mm between both eyes regardless absolute
Retrobulbar Haemorrhage When an orbital vessel ruptures blood products into the orbit. Since closed space, any added contents increase pressure inside the orbit potential damage to the ocular structures. Look for: non-pulsating exophthalmos with resistance to retropulsion, elevated IOP, EOM restriction, central retinal artery pulsation (indicating a possible impending central retinal artery occlusion), choroidal folds, and possibly signs of optic neuropathy.
Orbital Floor Blow-out fracture Symptoms Vertical (UP + Down Gaze) diplopia: mechanical entrapment of inferior rectus inferior oblique belly Adjacent fat / CT Hge + oedema of orbital fat/ CT Direct injury to muscle. look for : infraorbital hyposthesia and enophthalmos. Limited vertical mobility Intraocular damage
ORBITAL CELLULITIS Potentially blinding + life threatening especially in children Source of infection: Spread from periorbital tissues: sinuses, face, eye Direct inoculation of orbit from trauma or surgery Haematogenous spread from bacteraemia
ORBITAL CELLULITIS Cardinal signs: Proptosis Restricted eye movement Other signs: Patient is unwell, malaise Fever, headache Tenderness over sinuses Pain on eye movements Lid oedema and Chemosis Reduced vision/diplopia RAPD
Preseptal Cellulitis NO proptosis NO limited eye movement NO reduced vision ( after clearing any discharge) Patient is NOT toxic (Fever, lid oedema and hyperaemia, facial pain)
Palpate the eyelids for crepitus or subcutaneous emphysema. A positive finding indicates that air from a sinus has formed pockets within the orbital tissues. Feel Pulsations /Thrill Carotid-cavernous Fistula Evaluate orbital integrity: Palpate the orbital margins for a bony step-off that would be a clear sign of a fracture.
Feel Compare ipsilateral and contralateral cheek and forehead sensitivity:
Listen Audible Orbital Bruit Carotidocavernous Fistula ( High velocity fistula) an abrupt onset usually caused by a traumatic basal skull fracture. Look for: an audible orbital bruit, pulsatile proptosis, chemosis, orbital swelling, elevated IOP, ophthalmoplegia, and retinal vessel congestion.
Conjunctiva
Conjunctiva Look for: Local or generalised inflammation Discolouration Lesions wounds Pull down lower lid and evert upper lid
Chemosis (oedema)
Conjunctival Abrasions/ Lacerations Abrasions: fluorescein staining and may produce some degree of subconjunctival haemorrhage Lacerations significant haemorrhaging and typically have exposed white sclera. conjunctival edges have a tendency to be rolled due to the elastic nature of conjunctive. If a laceration is large, consider suturing, but most lacerations will heal without surgical repair.
Always : Inspect the fornices thoroughly Evert the eyelids to look for occult palpebral conjunctival FB which can cause corneal track marks.
Look for : Colour Wounds inflammation Sclera
Sclera Yellow sclera (icterus): in liver or blood disorders that cause hyperbilirubinemia. Muddy-brown discoloration common among dark / African people (a variant of normal).
SCLERITIS Very painful (BORING+++) More florid inflammation Distortion of pattern of vascular plexus with loss of radial pattern No blanching with Phenylepherine 10% drops
Scleral Lacerations Refer
Cornea
Cornea Look for : Clarity Wounds/FB Stain with fluorescein Abrasions/ ulcers Seidle test (if suspecting penetrating injury)
Corneal and conjunctival FB Corneal abrasions negative Seidel test. +ve fluorescein stain Corneal laceration +ve seidle test
Corneal ulcers and Keratitis Corneal oedema ( cloudy cornea)
The Anterior Chamber
Anterior Chamber Content: Blood Pus FB Lens Depth: compare both eyes Shallow Deep Irregular
AC contents
Anterior Chamber Depth Fully illuminated = Grade4 >2/3 illuminated = Grade3 1/3-2/3 illuminated=grade2 <1/3 illuminated=grade1 DEEP AC angle DEEP AC angle Shallow AC angle Closed/very narrow AC angle Iris closer to cornea Eclipse sign
Iris and Pupil Look for: Size & shape of pupil margin Normal light reflex/ RAPD Distortion towards limbus ( Peaked Pupil) Iris defects Normal pupil ( Round regular reactive equal in size, no RAPD)
Traumatic iritis History of trauma is critical Presentation: photophobia in both the involved + uninvolved eye (because of consensual pupillary constriction), perilimbal injection, cells and flare in the anterior chamber.
Pupil Sphincter Tear Peaked Pupil
Iridodialysis Detachment of the iris root from the ciliary body Presentation: irregular pupil shape- D shaped, pseudopolycoria, diplopia. Be aware of other iris defects
Different iris colour Congenital Acquired ( History of trauma + retained iron FB)
Lens Clarity Position In place AC PC In Pupil Stability: Tremors
Clarity/Position
Posterior Segment Examination
Posterior Segment Examination Look for: red reflex: Bright Dim Grey Absent Details: Optic nerve Retina Vessels Vitreous
Direct Ophthalmoscopy Get to know your scope FIRST
Direct Ophthalmoscopy(1) Red Reflex: With lens power of ophthalmoscope turned to 0 stand at arm's length from the patient and shine the light from the ophthalmoscope into the pupil.
Normal red reflex: Yellow/orange/bright red glow (reflection from choroidal vessels). The area is round in shape and evenly lighted Indicates no obstruction between you and patient retina Abnormal reflex Any opacity =dark area In retinal detachment reflex appears grey instead of red
Do you see clear red?
Fundus: Direct Ophthalmoscopy(2) When you do get a red reflex, move slowly as close as possible towards patient Your forehead touches your thumb which is used to lift upper lid of eye examined.
Fundus: The refractive power of the examiner and patient should be compensated for by adjusting the lens power of ophthalmoscope. Ask patient to look at a distant object. For right fundus examination: Hold instrument with right hand Use your right eye Approach patient from the right side
Various Findings
Pre-retinal Haemorrhage/ Vitreous Hge Visual acuity can be severely reduced if it lies in front of the macula. Gravity will cause the blood to settle into the quintessential "keel-shape" with the blood being darker on the bottom. In Vitreous hge : very dim red reflex
(Traumatic) retinal detachment
Purtscher's Retinopathy An injury that includes either : major chest compression (air bags) or head trauma Signs: cotton-wool spots and hemorrhages along the retinal arcades This diagnosis is driven first by history and then by the clinical presentation. Although not completely understood, Purtscher's retinopathy may be due to arterial and venous back-flow into the retinal vessels. Patients should be reassured that the condition tends to resolve without treatment, but they should be dilated every 2 to 3 weeks until resolution occurs
Disc oedema Optic disc atrophy
Optic nerve avulsion Avulsion can occur after severe trauma or relatively minor insults, but always results in devastating loss of vision.
Central / Branch Retinal Vein Occlusion
Central Retinal Artery Occlusion
Putting it all together Know your anatomy History is of great importance Assess function of the eye VA/Pupil/VF/EOM/IOP Assess structure of eye from outside in. Lid /lacrimal/orbit Conj/sclera Cornea AC Pupil /iris Lens Red reflex /fundus