General Ophthalmic Evaluation and Management

Dr. Mazhry frcs,fcps
Introduction to General Ophthalmic
Evaluation and Management
Dr. Zia-Ul-Mazhry
FCPS(Pak),
FRCS(Edin),
FRCS(Glasgow),
CIC Ophth- (UK)
Associate Professor
Head of Eye Department
Central Park Medical College &
WAPDA Teaching Hospital Complex Lahore
Pakistan

For Education purpose only
• No financial disclosure needed
• Images and material copied from different
Internet resources for teaching of
undergraduate ophthalmology students
2

Intended Learning Outcomes
Practical & Professional Skills:
– Perform examination of adnexa of the eye.
– Measure visual acuity.
– Test visual field.
– Test extra ocular muscle motility.
– Examine pupillary light reflex.
– Examine anterior segment of the eye.
3

Intended Learning Outcomes
Practical & Professional Skills:
– Practice Basics of health and patient’s safety and safety
procedures during practical and clinical years.
– Communicate clearly, sensitively and effectively with
patients regardless of their social, cultural or ethnic
background.
– To formulate a working
– To decide about Additional laboratory or imaging
studies to confirm the clinical diagnosis.
– To initiate a proper treatment/referral plan can be
instituted.
4

Disc Quiz- Match with Correct labels
MCQ-1
MCQ-3
MCQ-2
MCQ-4
Normal Optic Disc
A. Hypertensive Papillopathy
B. Disc swelling
C. Optic Atrophy
D. Glaucomatous Cupping

Retina Quiz- Match with Correct labels
MCQ-5
MCQ-7
MCQ-6
MCQ-8
Normal Retinal Appearance
A. CRVO
B. Retinitis Pigmantosa
C. Myopic Degeneration
D. Diabetic Retinopathy

MCQ-9
• Test being
performed is:
a. Applanation tonometery
b. Schiot’s tonometery
c. Air Puff Tonometery
d. Digital Tonometery

MCQ-10
• Test being performed
is known as:
a. FFA
b. CT scan
c. B scan
d. MRI

• Physicians who will make the effort to learn,
develop, and practice the skills required for
ocular examination will be rewarded by
observing many important clinical findings
that will often assist in diagnosing and treating
their patients. The reverse is also true. Those
who forego an ocular examination may miss
physical findings vital to the correct diagnosis
and thus proper treatment of the patient’s
ocular or systemic diseases
Introduction

Context
• Eye complaints are common in general
practice1.5% of all consultations1
• GP ideally placed to triage – what can be
reassured and what needs referral
1) SHELDRICK JH, WILSON AD, VERNON SA, SHELDRICK CM. Management of ophthalmic disease in general practice Br J Gen Pract1993;
43(376): 459–62

Requirements for a structural
examination of the eye
1. Snellen Eye Chart
2. Near Vision Eye Card
3. Bright Penlight or Transilluminator
4. Direct Ophthalmoscope
5. Sterile Fluorescein Strips
6. Sterile Irrigating Solution
Optional accessories include a pinhole viewer, various
occluders, and cotton-tipped applicators. The
ophthalmoscope is the only expensive instrument required for
the examination. All other equipment is quite inexpensive.

Tools
• Snellen chart
• Pinhole
• Torch with blue filter
• Fluorescein
• Red pin
• Drugs
– Topical anaesthetic
• Proxymetacaine
– Topical mydriatic
• Tropicamide (short-acting)
• Cyclopentolate
• Ophthalmoscope

Why Examine the Eyes?
• 75% of our sensory stimuli arrive via the eyes.
• examination of the eyes can lead s to observe
many types of abnormalities of the visual
system, cranial nerves, and brain.
• An opportunity for direct examination of
living tissues
• Ocular vs systemic and systemic vs. oculr
associations

A. Ocular Complaints
• Ocular complaints can be grouped into six
large categories:
– (1) visual complaints,
– (2) pain in and around the eye,
– (3) a red eye,
– (4) flashes and floaters,
– (5) diplopia, or
– (6) trauma to the eye and/or orbit.

Visual Complaints
How to Examine the Eyes: History

• Pain in and around the Eye

3. Red Eye
Conjunctivitis Iritis (Anterior Uveitis)
Angle Closure
Glaucoma
Visual Acuity Normal
Normal or Slightly
Reduced
Decreased
Pain Irritation (Mild) Mild to Moderate Severe
Photophobia No Severe Variable
Discharge Yes, Purulent Tearing Tearing
Pupil Normal
Small, Sometimes
Irregular
Mid-Dilated and
Fixed
Anterior Chamber Deep Deep Shallow
Cornea Clear Clear Cloudy
Systemic Symptoms None None
Nausea and/or
Vomiting

4. Flashes and Floaters

• 5. Diplopia (Double Vision)
– Confusion vs. diplopia
• True diplopia always binocular
– Vertical vs. horizontal
– Associated Neurological Symproms
– H/O Vascular Diseases

• 6. Trauma to the Eye and/or Orbit
– Nature
– Circumstances
– Intactness of globe
– Possibility of intraocular foreign body

B. History of Present Illness
• The history of the patient’s present illness is
developed into a narrative that describes the
development of the complaints over time

C. Past Medical History
• patient’s past medical diseases,
• surgeries,
• and response to therapy

D. Family History
• (1) glaucoma,
• (2) cataracts,
• (3) strabismus, and
• (4) blindness

E. Medication History
• Systemic
– Past
– Present
• Ocular
– Past
– Present
• Allergies

F. Nutritional History
• Vitamin A defficiency
• Alcoholics
• Nutritional Optic Atrophy

G. Sexual History

H. Review of Systems
• specific questions about organ systems

A. Clinical Anatomy Of The Eye
Anatomy Of The Ocular FundusExternal Anatomy Of The Eye
V. How to Examine Eyes: Physical Examination

B. Visual Acuity

Variations of Peeking by Patient - You Must Be Alert For This

Light PL vs.PR

VA
RE: 6/6
OD: 20/20
With (cc) or Without correction (sc)
LE: 6/6
OS: 20/20
Visual acuity is documented in the chart in the
following fashion:
OD is the abbreviation for Oculus Dexter (the RIGHT
eye-RE), and OS is the abbreviation for Oculus
Sinister (the LEFT eye-LE).

Measuring Visual Acuity of the Right Eye with the Pinhole

C. Examination of the Eyelids and Orbit

Bilateral Lid Retraction in a Young Patient With
Graves' Disease

Note Proptosis of Left Eye Easily Seen
by Viewing the Relative Positions of
the Eyes from over the Brow

eyelids and the eyelashes are examined

Conjunctival Examination
D. Examination of the Conjunctiva/ Sclera

Examinationoftheupper
palpebralconjunctival

Eversion of the upper lid is accomplished
by following these steps:
1) Explain to the patient what you are about to do. This is not a painful
examination but may induce squeezing in some patients.
2) Instruct the patient to look down but keep both eyes open. This is
imperative for the success of the examination.
3) Grasp the lashes of the upper lid in the center and pull
downward. Placing your thumb or a cotton-tipped applicator on the
upper lid above the lid crease, simultaneously pull up the lashes and
push down the cotton-tipped applicator or thumb. The lid should
evert.
4) Secure the lashes between your thumb and the patient’s brow to
keep the lid everted while the examination continues.
5) Study the exposed palpebral conjunctiva and carefully look for
foreign material. Prior use of fluorescein may assist in identifying
light-colored materials such as sawdust.
6) Upon completion of the examination, release the upper lid. The
patient will usually blink, returning the lid to its normal position. If it
does not return spontaneously, instruct the patient to look up.

E. Examination of the Cornea
• Examining the cornea involves two
observations.
– The first is to evaluate the overall clarity of the
cornea;
– the second is to examine the quality of the corneal
reflection.

Staining the tear film with
fluorescein may help evaluate
the conjunctival and corneal
surfaces. Fluorescein is usually
applied from a sterile strip
moistened with a drop or two of
sterile irrigating solution. If
using the larger strips, peel back
the outer wrapper and tear off
the strip so that about ¼ inch of
the stained area of the strip
remains adjacent to the
unstained “handle.” This
amount of fluorescein should be
sufficient for any examination

The patient is instructed to look upward and the moistened strip gently touched to
the lower lid margin. The patient is asked to blink several times to spread the
dye. A Wood’s lamp or other blue filter is used to illuminate the ocular
surface. Areas where the epithelium is disrupted will take up the dye and stain a
bright yellow-green when viewed with a Wood’s lamp or cobalt blue filter. It is not
necessary to wash the remaining fluorescein from the eye.

Do not use fluorescein if the patient is wearing soft contact lenses, as this action will
cause permanent staining of the lenses. Remove the lenses and instruct the patient
not to reinsert the contacts for at least 4 hours. Patients with obvious corneal or
scleral lacerations do not require the instillation of fluorescein to adequately
evaluate their injuries.

Hyphema
F. Examination of the Anterior Chamber

Anterior chamber depth assessment
• Likely shallow if
– ≥ 2/3 of nasal iris in shadow

Examination of the Depth of Anterior
Chamber

Pupillary
Size

Pupillary Examination
• Direct penlight into eye while patient looking
at distance
• Direct
– Constriction of ipsilateral eye
• Consensual
– Constriction of contralateral eye

Direct and Consensual Light Reflex

Consensual Light Reflex
This reflex is checked in the same way as the direct
pupillary light reflex, but observe the reaction in the
other eye. A normal consensual response in an eye
with a nonreactive pupil indicates the presence of a
severe afferent arc defect on the side with the
nonreactive pupil. A nonreactive pupil that fails to
respond to consensual stimulation has a defect in the
efferent arc of the eye with the nonreactive
pupil. The cause could be a palsy of cranial nerve III
or the result of structural (traumatic or surgical) or
pharmacologic changes in the pupil.

Relative Afferent Pupillary
Defect (RAPD)

Abnormal RAPD

Accommodative (Near) Pupillary
Reflex
Examination of the near reflex is not required for every pupil
examination. If, however, the direct light response is absent
in one or both pupils, then the accommodative (near) reflex
must be evaluated.
The patient fixates on a distant target. The physician holds
an object in the patient's midline, and then asks the patient
to look at this near target. Three actions should occur:
1. Miosis (constriction) of the pupils
2. Convergence (the two eyes move inward)
3. Accommodation (the cilary muscle contracts,
focusing the lens at the near object)

H. Examination of the Extraocular Muscles
Two characteristics of the extraocular muscles must be
evaluated: ocular alignment and conjugate movement of
the eyes (ocular versions).
Ocular Alignment
Alignment of the visual axes is tested by one of two
methods:
(1) light reflex test or
(2) alternate (cross) cover test.
The alternate cover test is more sensitive but requires a
higher level of patient cooperation. Patients with poor or
no vision in one eye cannot be tested accurately with the
alternate cover test.

Ocular Motility
Rt superior rectus
Lt inferior oblique
Lt superior rectus
Rt inferior oblique
Rt lateral rectus
Lt medial rectus
Lt lateral rectus
Rt medial rectus
Rt inferior rectus
Lt superior oblique
Lt inferior rectus
Rt superior oblique

Corneal
Reflection Test
Light
Reflex
Test/
Hirchberg
test

Alternate (Cross) Cover Test

Alternate Cover Test Demonstrating OUTWARD Motion
of Eyes During Testing Indicating ESO-Deviation of Eyes
(Patient's Eyes Turn INWARD)
Simulation With Prism

Alternate Cover Test Demonstrating INWARD Motion of
Eyes During Testing Indicating EXO-Deviation (Patient's
Eyes Turn OUTWARD)

Alternate Cover Test Demonstrating Vertical Deviation
(Left HYPERTROPIA - Left Eye Higher)

Actual Patient With ESOphoria

Actual Patient With EXOphoria

Ocular Versions

Ocular Ductions of Right Eye
(Four Directions)

Example of
Pure
Horizontal
Diplopia
- Note
Continuity
of
- Shoreline
Evaluation of Patient with Diplopia

Example
of Pure
Vertical
Diplopia

Example
of
Oblique
Diplopia

Patient with Right Sixth Nerve Palsy

Example of Third Cranial Nerve Palsy
on the Right Side

Example of a Left Fourth Cranial Nerve
Palsy

I. Confrontation Visual Fields

Measurement of IOP
• •Digital method
•Indentation tonometry (schoitz)
•Applanation tonometry (Gold-man)
•Non-contact (air) tonometry

J. Estimation of the Intraocular pressure by Tactile Tension (TT)

Intraocular Pressure Measurement
• Range: 10 - 22

K. Examination of the Red Reflex
Examination of the red reflex is accomplished with the direct ophthalmoscope. The
instrument is held in the same fashion as for viewing the fundus, but the eye is
viewed from a distance of between arm's length and 8 - 10 inches. The lens wheel
will need to be focused at about +2 (green or black numbers) for a distance of 20
inches up to about +5 at a distance of 8 inches. The object is to focus the
ophthalmoscope at the level of the pupil rather than at the level of the
fundus. While this is best done with a dilated pupil, an examination carried out in a
dark room will often lead to satisfactory viewing of the red reflex.
The red reflex of each of the patient's eyes should be viewed and the quality of the
red reflex compared. Abnormal shadows or differences in the red reflex between
the two eyes require consultation with an ophthalmologist.
Below are several examples abnormal appearances of the red reflex in various
disease states:
Cataract - Nuclear
Cataract - Posterior Subcapsular
Cataract - Cortical
Leukocoria - Retinoblastoma

Examination of the Red Reflex
Abnormal Red Reflex Due To Nuclear Cataract

Abnormal Red Reflex in Patient with Posterior Subcapsular Cataract

Abnormal Red Reflex in Patient with Cortical Cataract

Abnormal Red Reflex in Patient with Cortical Cataract
Leukocoria Right Eye (upper photograph) caused by Retinoblastoma
Leukocoria Left Eye (lower photograph) caused by Retinoblastoma

You may set the lens wheel
to “0" (zero) to start
Proper Way to Hold the Direct Ophthalmoscope in
the Left and Right Hands

Proper Technique for Examination of the
Right and Left Eye
With the Direct Ophthalmoscope

Five parameters of the disc are observed and recorded:
1. Color – Is the disc normal pink, hyperemic, or pale?

2. Contour – Is the disc elevated or flat?

3. Circumference – Is the disc margin sharp or blurred?

4. Cup/disc ratio – What is the relationship between the
cup size and the disc size?

5. Spontaneous venous pulsations - present or absent?
Spontaneous venous pulsations are best seen
by looking at the large veins on the disc.

Examination of Retinal Vessels

Hypertensive Retinopathy

Vascular Accidents

Diabetic Retinopathy

Systematic Viewing of the Fundus

Macular/Foveal Evaluation

Management Plan
After you have completed a careful
recording of the clinical history of the
patient’s complaints and a thorough
examination of the eyes and their adnexa,
a working diagnosis should be
achieved. Additional laboratory or
imaging studies may be required to
confirm the clinical diagnosis. Once the
diagnosis has been made, a proper
treatment plan can be instituted.

Invistigations
• FFA Fundus fluorescein angiography
• Perimetry
• Ultrasound
• CT
• MRI
• Electrophysiological studies

Visual field
Indications Automated Perimetery
• Diagnosis & follow up of
glaucoma
optic n. diseases
retinal diseases
• Neuro-ophthalmological
disorders

Ultrasound
• Ultrasonography
– Examination of post.
Segment in opaque
– Media
– Detection of IOFB (site
& nature)
– Diagnosis of orbital
diseases (Thyrotoxic)
– Measurement of axial
length of the eye

Principles of Management
• Treat the Symptoms
• Treat the Cause
• Treat the Complications
– Of the disease
– Of the treatment itself

Guidelines for ocular referrals
Immediate
– Non-traumatic red eye
• Acute glaucoma
• Painful eye after cataract op
– Traumatic red eye
• Chemical burn
• Corneal laceration
• Globe perforation
– Sudden visual loss
• Giant cell arteritis
• Retinal artery occlusion (if visual loss is less than 6 hrs)
• Any visual loss of less than 6 hrs ?cause
– Third nerve palsy with dilated pupil

Same day
– Red eye
• iritis
• Corneal infection
– Trauma
• Blunt trauma
• Corneal abrasion
• Foreign body
– Swollen lids
• Herpes zoster with ocular involvement – Hutchinson’s sign
• Orbital cellulitis
– Sudden visual loss
• Vitreous haemorrhage
• Sudden visual loss of more than 6 hrs
• Sudden onset floaters
• Retinal detachment

Same week or not at all
• Same week
– Persistent conjunctivitis
– Episcleritis
– Facial nerve palsy
• Unless there is severe corneal exposure then within 24hrs
• No referral needed
• Painless sticky eye of less than 24 hrs
• Chalazion

Summary of steps in eye exam
• Visual Acuity
• Pupillary examination
• Visual fields by
confrontation
• Extraocular movements
• Inspection of
– lid and surrounding
tissue
– conjunctiva and sclera
– cornea and iris
• Anterior chamber depth
• Lens clarity
• Tonometry
• Fundus examination
– Disc
– Macula
– vessels

Common ocular signs and symptoms terminology
• Photopsia= seeing flashes of light
• Photophobia= abnormal sensitivity to light
• Epiphora= overflow of tears due to defective drainage
• Metamorphopsia= distorted images
• Floaters= flying and moving lines and dots
• Micropsia= small images
• Macropsia= large images
• Halos= circles around light sources
• Scotoma= defect in the field of vision
• Dyschromatopsia= disturbed color vision
• Nyctalopia= night blindness
• Diplopia= double vision
• Anopia = loss vision in one eye
• Hemianopia= half visual field defect for both eyes
• Glare= visual defect infront of light source
• Amourosis fugax= uniocular transient loss of vision
• Cotton wools= infarcted retinal nerve fibers
• Papilloedema= bilateral disc swelling due to raised intracranial
pressure
• Anisocoria=unequal pupils
• Heterochromia iridis= different colored irises
• Microphthalmia= small disorganized eye
• Nanophthalmia or macrophthalmia= normal small or large globe
• Aniridia= absence of iris
• Blepharitis = inflammation of eyelids
• Buphthalmus= large globe in pediatric glaucoma
• Hypotony = low intraocular pressure
• Keratoconus = cone shaped cornea
• Proptosis( exophthalmos)= forward globe displacement
• Ptosis= dropping of the upper eyelid
• Enophthalmos= backward globe displacement
• Trichiasis= inward directed eyelashes
• Ectropion =outward directed lid margin
• Entopion= inward directed lid margin
• Lagophthalmos= incomplete lid closure
• Lid lag = decrease lid descent on down gaze
• Lid retraction = elevated lid
• Nebula ,macula and leukoma= grades of corneal opacity
• Vogt stria= stretch lines on descemet membrane
• Descematocele= exposed descemet membrane
• Keratic precipitate= inflammatory cells on the corneal endothelium
• Hypopyon= pus in the anterior chamber
• Hyphema = blood in the anterior chamber
• Anterior and posterior synechia= adhesion of the iris with the
cornea and the lens(respectively)
• Aphakia =no lens
• Pseudophakia= artificial intraocular lens
• Rubeosis= iris neovascularization
• Poliosis= depigmented eyelashes
• Madarosis= loss of eyelashes
• Staphyloma= protruded thinned part of the eyeball
• Symplepharon= adhesions between bulbar and lid conjunctiva
• Tropia =squint =strabismus
• Exotropia=divergent squint esotropia= convergent squint
• Pannus = abnormal blood vessels invading the cornea

The Rewards
The rewards of determining an
accurate diagnosis from a skillfully
performed history and physical
examination and watching the
patient respond to appropriate
therapy is one of the greatest
sources of personal satisfaction one
can experience as a physician.

…for listening

General Ophthalmic Evaluation and Management

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to General Ophthalmic Evaluation and Management

Similar to General Ophthalmic Evaluation and Management (20)

More from Central Park Medical College and WAPDA Teaching Hospital Lahore

More from Central Park Medical College and WAPDA Teaching Hospital Lahore (19)

Recently uploaded

Recently uploaded (20)

General Ophthalmic Evaluation and Management