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Ophthalmoscopy & otoscopy


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Ophthalmoscopy & otoscopy

  1. 1. By Dr-Wedad Bardisi
  2. 2.  It is an instrument about the size of a small flashlight with several lenses that can magnify up to about 15 times.  This type of ophthalmoscope is most commonly used during a routine physical examination
  3. 3.  An indirect ophthalmoscope constitutes a light attached to a headband, in addition to a small handheld lens. It provides a wider view of the inside of the eye. Furthermore, it allows a better view of the fundus of the eye, even if the lens is clouded by cataracts.  An indirect ophthalmoscope can be either monocular or binocular
  4. 4.  Establish good Doctor- Patient relationship.  Take his permission.  Explain what are you going to do and why.  Examine the eye generally by inspection for any obvious abnormalities like ptosis, exophthalmous, conjunctivitis, scleritis, swellings or ptyrigium which can mechanically impairs the direct ophthalomoscopy.
  5. 5.  Shine torsh light to both eyes to look for the red reflex so to exclude cataract which may impairs the procedure.  Inspect the size of the pupils.
  6. 6.  If it is small you need to darken the room, if this fails to dilate the pupil sufficiently, then use mydriatic, for example , mydrilate(1% cyclopentolate), can be installed. This should never be done in the unconscious patient and must always be recorded in the patient notes.
  7. 7.  Do not use mydriatics in a patient with glaucoma.  Rememberto revese the effect of medriatic at the end of the examination by installing 2% pilocarpine.
  8. 8.  Ask the patient to fixate on a distant target.  If the patient wears glasses with a substantial correction, It some times facilitate the examination to perform it with the patients glasses in place.
  9. 9.  The optic disc is examined to assess its shape, colour and clarity.  The temporal margin of the disc is slightly paler than the nasal margin. The physiological cup varies in size but seldom extends to the temporal and never to the nasal margins of the disc.
  10. 10.  The blood vessels are not obscured as they cross the disc , nor they are elevated.  The vessels are examined next, the arteries are narrower than the veins and a brighter in color.  They posses a longitudinal pale streak as a consequence of light reflecting from their walls.
  11. 11.  The retinal veins should be closely inspected where they enter the optic disc.  In approximately 80% of individuals the veins pulsate. This pulsation ceases when CSF pressure increase, therefore the presence of this retinal venous pulsation is very sensitive index of normal intracranial pressure.
  12. 12.  The fundus is examined for the presence of haemorrhage or exudates, the position of which are best shown by a diagram in the patient notes.
  13. 13.  Clinical application  Optic atrophy  Papilloedema  Retinal artery and vein occlusion.  Hypertensive retinopathy  Diabetic retinopathy  Glaucoma
  14. 14.  It is useful to characterize the changes in the optic nerve head that occur in papilledema as being mechanical or vascular in nature.
  15. 15. 1. Blurring of the optic disc margins 2. Filling-in of the optic disc cup 3. Anterior extension of the nerve head (3D = 1mm of elevation) 4. Edema of the nerve fiber layer 5. Retinal and/or choroidal folds.
  16. 16.  1. Venous congestion of arcuate and peripapillary vessels 2. Papillary and retinal peripapillary hemorrhages 3. Nerve fiber layer infarcts (cotton-wool spots) 4. Hyperemia of the optic nerve head 5. Hard exudates of the optic disc
  17. 17.  Papilledema is classified as: A. Early B. Fully developed C. Chronic D. Late Early papilledema: 1-Disc hyperemia 2- Disc swelling 3-Blurring of the disc margins 4-Blurring of the nerve fiber layer
  18. 18.  Fully developed papilledema: 1.Gross elevation of the optic nerve head 2. Engorged and dusky veins appear. 3. Peripapillary splinter hemorrhages and sometimes choroidal folds arise 4. Retina striae
  19. 19.  In chronic papilledema: 1. Fewer hemorrhages occur. 2. The optic disc cup is obliterated completely. 3. Less disc hyperemia is seen. 4. Hard exudates occur within the nerve head. 5. Optociliary shunts can start showing.
  20. 20. In late disc edema: 1-Secondary optic atrophy occurs 2-Disc swelling subsides 3-Retinal arterioles are narrowed or sheathed 4-The optic disc appears dirty gray and blurred, secondary to gliosis 5-Retinochoroidal vein shunts(or Optociliary) may be seen
  21. 21.  Headache.  Brief transient obscurations of vision.  Less commonly, blurred vision, constriction of visual fields, dyschromatopsia, and/or diplopia.  Cause for concern exists if the headache is particularly severe or associated with nausea and vomiting or a sense of pressure around the ears. .
  22. 22.  Papilledema showing blurred disc margins and dilated tortuous vessels .
  23. 23.  Age related macular degeneration (AMD) is one of the most common causes of poor vision after age 60.  The specific cause is unknown, AMD seems to be part of aging.  Age is the most significant risk factor for developing AMD.  Heredity, blue eyes, high blood pressure, cardiovascular disease, and smoking have also been identified as risk factors.  AMD accounts for 90 percent of new legal blindness in the US.
  24. 24.  Nine out of 10 people have dry AMD which results in thinning of the macula.  Dry AMD takes many years to develop.  Currently no treatment
  25. 25.  The wet form of AMD occurs much less frequently (one out of 10 people) but is more serious.  In the meantime, high-intensity reading lamps, magnifiers and other low-vision aids help people with AMD make the most of remaining vision.
  26. 26.  is the loss of some or most of the fibers of the optic nerve.  loss of vision , colour vision. Causes  Optic atrophy can be congenital or acquired  anterior ischemic optic neuropathy or  posterior ischemic optic neuropathy.  optic neuritis  Tumour
  27. 27.  diabetes mellitus, trauma, glaucoma, or toxicity (caused by methanol, tobacco, or other poisons).  It is also seen in vitamin B12 deficiency and Paget's disease of the bone.
  28. 28.  Toxoplasmosis is a common parasitic infection. When contracted by a pregnant woman, toxoplasmosis can pose serious risks to the unborn baby.  Simple precautions can reduce the chance of infection.
  29. 29.  Pregnant women should avoid handling litter boxes and eating raw meat because the parasite may originate in cat feces or undercooked meat.  If acquired during the first trimester of pregnancy, the infection can be devastating to an infant.
  30. 30.  Central retinal vein occlusion (CRVO) blocks the main vein in the retina.  The blockage causes macular oedema, vision becomes blurred.  Floaters due to blood in the vitreous. Retinal vein occlusions commonly occur with glaucoma, diabetes, age-related vascular disease, high blood pressure, and blood disorders.
  31. 31.  CRAO usually occurs in people between the ages of 50 and 70.  The most common medical problem associated with CRAO is arteriosclerosis.  Carotid artery disease is found in almost half of the people with CRAO.  The most common cause of CRAO is a thrombosis. Sometimes CRAO is caused by an embolus.  Central retinal artery occlusion (CRAO) blocks the central artery in retina, the ligh.  The first sign of CRAO is a sudden and painless loss of vision.
  32. 32.  Loss of vision can be permanent without immediate treatment.  Irreversible retinal damage occurs after 90 minutes, but even 24 hours after symptoms begin, vision may still rarely be saved.  The goal of emergency treatment is to restore retinal blood flow
  33. 33. Back ground diabetic retinopathy
  34. 34.  Microaneurysms: these are usually the earliest visible change in retinopathy seen on exam with an ophthalmoscope as scattered red spots in the retina where tiny, weakened blood vessels have ballooned out.  Hemorrhages: bleeding occurs from damaged blood vessels into the retinal layers. This will not affect vision unless the bleeding occurs in or near the Macula  Hard Exudates: caused by proteins and lipids from the blood leaking into the retina through damaged blood vessels. They appear on the ophthalmoscope as hard white or yellow areas, sometimes in a ringlike structure around leaking capillaries. Again vision is not affected unless the macula is involved.
  35. 35.  Arteriosclerotic changes ◦ Arteriolar narrowing that is almost always bilateral.  Grade I - 3/4 normal caliber  Grade II - 1/2 normal caliber  Grade III - 1/3 normal caliber  Grade IV - thread-like or invisible ◦ Arterio-venous crossing changes (aka "AV nicking") with venous constriction and banking ◦ Arteriolar color changes
  36. 36.  Copper wire arterioles are those arterioles in which the central light reflex occupies most of the width of the arteriole.  Silver wire arterioles are those arterioles in which the central light reflex occupies all of the width of the arteriole. ◦ Vessel sclerosis.
  37. 37.  Ischemic changes (e.g. "cotton wool spots")  Hemorrhages, often flame shaped.  Edema ◦ Ring of exudates around the retina called a "macular star"  Papilledema, or optic disc edema, in patients with malignant hypertension  Visual acuity loss, typically due to macular involvement
  38. 38.  A 23 year old man had had intermittent odourless discharge from his right ear for two years since experiencing sudden earache while diving on holiday.  He felt he was deaf in that ear and had recently noticed some high pitched tinnitus on the right, although his ear was currently dry.  What does otoscopy of his right tympanic membrane show?
  39. 39.  There is a perforation of the posterosuperior quadrant of the tympanic membrane.  No cholesteatoma is visible, and the intact long process of the incus and stapes head can be seen through the perforation
  40. 40.  A 5 year old girl had multiple attacks of otitis media, was falling behind in her schoolwork, and was mispronouncing words. Her teacher felt she was not paying attention in class and her parents noticed that she turned up the television volume to unacceptably loud levels. The picture above shows the otoscopic appearances. What is the likely diagnosis?
  41. 41.  The tympanic membrane is intact but is dull and a golden colour.  This child has otitis media with effusion (glue ear). If this is persistent she may benefit from the insertion of ventilation tubes (grommets
  42. 42.  A 28 year old woman had put up with an intermittent foul smelling discharge from her ear for over 10 years.  Topical antibiotics controlled her symptoms for only a few weeks. She had suddenly become very deaf in the affected ear and had asked for a specialist opinion. What do the otoscopic findings suggest?
  43. 43.  There is a large mass of infected squamous epithelium and keratin behind the pars flaccida - a cholesteatoma.  This can cause infective complications such as meningitis and may erode into the labyrinth or facial nerve.  The cholesteatoma therefore needs to be removed.  The operation entails exploring the mastoid to identify the fundus of the sac, removing the disease, and grafting the surgical defect.