4 th grade medical students basic ophthalmology examination

1. Ophthalmology sheet
Ahmed Osama Hashem
PhD,MD ,FRCS
Lecturer, consultant of ophthalmology

2. Complaint of patient
• HOW TO COMMENT on complaint of patient? : You must fulfill certain
items:
1)
• The main complaint : examples:
- Painless progressive diminution of vision.
-Drooping of upper eye lid.
-Squinting of the eye .

3. Complaint of patient
2) Side: if the complaint is present in the Rt. eye or Lt. eye or both
eyes.

4. 3) History of present illness:
• a) Onset: sudden,gradual.
• b) Course: progressive,stationary.
• c) Duration: : Examples: Complaint of patient: Painless progressive
diminution of vision in the Rt eye since one year , in the Lt. eye since
3 years. Complaint of patient: Drooping of the Rt. upper lid since
birth.

5. Past History, You should ask the patient:
• Diabetes.
• Hypertension.
• History of trauma.
• Operations Ocular.
• Ocular drugs. (And allergy to certain drugs !! i.e blephamide ,,, COPD
& BB)

6. Family history (FH)
• This is relevant both to diseases with a significant genetic component
(e.g. retinitis pigmentosa (RP), glaucoma, some corneal dystrophies;
there may be consanguinity) and to infective conditions (e.g.
conjunctivitis, tuberculosis (TB), etc.)

7. Visual acuity testing

8. What does 6/6 mean ? Meter ,,, feet ,,
numerator / denominator
6/9
6/12
6/18
6/60
5/60
1/60

9. Snellen chart

10. Commonest cause of dropped VA Refractive
error

11. Pinhole

12. Trial
• Trial frame ,, trial lenses

13. Phoropter

14. Near vision chart

15. Test macula function (Amsler grid)

18. Test color vision

19. Test contrast sensitivity

20. VA in children

22. Test VA in children
• hundreds and thousand test sweet test

23. Test VA in children
• preferential looking

25. Test VA in children
• Picture test

26. Sheridan Gardner

28. Pupil (very important)
Test pupil
Pupillary defect
A-Neurological lesion (tumor-MS)
B-Severe Ocular pathology
-Severe retinal disease
i.E RP Advanced
-Glaucoma, End stage

32. Lid examination
• a) Ptosis:If the upper eye lid is covering more than 1/6 of cornea, so
write (Ptosis) .
• b) Look for other diseases in the lid as Ectropion, Entropion, Rubbing
lashes, Trichiasis, Dermatochalesis.
• • If you find NOTHING of abnormalities (The Lid NORMAL), so write,,,

33. Surface Anatomy
• Superior Palpebral sulcus
• Lateral canthus
• Medial canthus
• Palpebral fissure (space b
-etween lid margis)
• Upper lid cover 1/6 ….
• Lower lid .. At level of ..

34. Anterior blepharitis
1. Seborrheic (scaly)

35. Complications

36. ptosis

37. Lacrimal apparatus examination:
• Gland not felt,
• -ve regurge

47. Cornea: examination:
• a) Examine the Rt. cornea.
• b) If you find corneal opacity : ⇒ if the corneal opacity is faint , so it's
nebula
• In nebula you should specify:
• • Site : i. If the nebula is opposite pupil , so it is central.
• ii. If the nebula is at the edge of the pupil, so it is paracentral.
• iii. If the nebula is near limbus, so it's peripheral.
• iv. If the nebula is involving two places , (opposite pupil & at the
edge of pupil ), central and paracentral
• v. If the nebula is involving THE THREE areas , so it's Diffuse
⇒ if the corneal opacity is dense , so it is leucoma

48. Cornea: examination:
• Type of leucoma: adherent or non adherent •
• If the pupil is rounded, so it's non adherent. •
• If the pupil is peaked toward the leucoma, so it's adherent

49. Cornea: examination:
• 2) Vascularized or not :
• • If you see CLEAR blood vessels, so it's vascularized.
• • If you see NO blood vessels, so it's non-vascularized.

50. Cornea: examination:
• Ask the patient to look down : • If you find Manson's sign so it's
Keratoconus.

51. Cornea: examination:
• comment on the peripheral cornea?
-"Pannus siccus ”
-"Arcus senilis", even if find abnormalities or

52. Anterior Chamber examination
• Anterior Chamber: Scheme:
• Depth depends on your diagnosis: *Aphakia, Pseudophakia or
Keratoconus, so it is Deep.
• Leucoma adherent, so it's of irregular depth.
• Only other diagnosis rather than above e.g. immature cataract, so it's
of normal depth.

53. Anterior Chamber examination
• You must write “Normal or abnormal contents”.

55. What you can see at the bottom of the cornea ?
What is the treatment ?

56. Iris examination
A) Look for iridectomy.
If you find iridectomy you must specify it’s type:
-peripheral iridectomy. - sector iridectomy. (pupil is irregular, removed till
limbus)
b) If the pupil is irregular and there is iris between limbus and pupil So it is
Synechia. If you find synechia you must specify it’s type:
-If there is leucoma AND pupil is pear shaped with it’s peak touching
leucoma So it is Anterior synechia.
- If the cornea is clear OR there is just Nebula OR Peak of pear shaped pupil
is away from cornea So it is Posterior synechia.
c) If your diagnosis is Aphakia, so iris is tremulous.
d)Loss of iris pattern,,,, uveitis

57. Anterior uveitis if not treated probably may
lead to sever complications, what are they ?

58. What is your main finding?

59. Mention 3 abnormal findings ?
Mention the most common cause?

60. HOW to comment on pupil:
• • If it is normal, Pupil: Rounded Regular Reactive. RRR. •
• If it is abnormal so, write: Pupil: rounded regular dilated irregular
irreactiveDrown up (synechia ,trauma).

61. Lens by torch
• a) Look at the color of the lens b) If the color of the pupil is black, so:
⇒
• Ask the patient about history of cataract operation
• If No cataract operation, so it is normal lens.
• History,,,, If there was cataract operation, proceed to next step. ⇒
Ask the patient about IOL implantation after cataract operation

71. Lens by torch
• And look for purkinje sanson image.
• ƒIf there is IOL implantation with 2 purkinje sanson image (one with
and one (against So it is Pseudophakia (IOL).Specify if it is ant or post.
• ƒIf there is NO IOL implantation with one purkinje sanson image So it
is Aphakia.

72. Lens by torch
• C)If the color of the lens is brown or grey : ⇒ Ask the patient about
history of cataract operation ƒIf there was cataract operation so After
cataract. ƒIf NO cataract operation so it is CATARACT.
• History of poor vision since birth,,drugs,trauma,systemic disease DM

73. Lens by torch
• • Look at the color of the opacity,
• a) If it is brown in color, so it is nuclear senile cataract
• b) If it is grey in color, so it is cortical senile cataract you should
specify its maturity, proceed next step

74. You can differentiate by VA
• • Measure vision of the patient, a) If he can count finger, so it is
immature cortical senile cataract b) If he only sees hand movement,
=mature.

75. Posterior dislocation,Aphakia,PCO
• How to diagnose ….? ƒPosterior dislocation? * It is similar to aphakia
(one purkinje sanson image) BUT * No history of operation + history
of trauma ƒSubluxation ....? * It is similar to cataract (cataractous lens)
BUT
• Iris tremulous

76. Poor Visual acuity
• Vision: Scheme:
• 1) Ask the patient to cover his Lt eye & ask him to count your fingers
at a distance of 20 cm, repeat more than one time If the patient can
count fingers at a distance of 20 cm, & ask him to count fingers at a
more away distance till your hand reaches one meter from patient If
the patient can count fingers till one meter, so write CF >1m (need
visual chart)
• If the patient can not count till one meter, make rough estimation of
distance that he can count finger [CF 20 cm <…

77. Visual acuity
• • If the patient can not count fingers at a distance of 20 cm, move
your hand & ask him to tell you whether there is something moving
or not & to tell you when it stops
• • If the patient can see movement of hand, so his vision is hand
movement (HM)
• • If the patient can not see movement of hand, put torch in front of
his eye & ask him whether he see light or not If the patient sees light,
so his vision is PL ,If the patient doesn't see light, so his vision is NO PL
• 2) Ask the patient to cover his Rt eye & examine vision of Lt eye in the
same manner

78. Visual acuity
• When to comment on projection? • When vision is:
• 1. CF 20 – 100 cm
• 2-HM,,,
• 3-Pl
• Scheme:
• 1) Ask the patient to cover his Lt eye & look foreword by his Rt eye
• 2) Ask him to point at direction of light in different direction• If the patient
knows ALL direction, so projection is good • If the patient makes mistake
even in only one direction, so projection is bad & you should specify this
direction
• 3) Ask the patient to cover his RT eye & examine his Lt eye in the same
manner

79. Visual acuity
• How to comment on projection…? •
• If projection is good in ALL directions, so write: good projection
• If projection is bad in one direction, you should specify in which
direction projection was bad.

80. Ocular Motility: How to comment on ocular
motility…?
• • Ocular movements
• :No limitation- limitation+_pain

81. Ocular motility
• 1) Test ocular motility in Rt eye then in Lt eye to differentiate bet
concomitant & paralytic squint
• in concomitant squint, there is NO limitation of ocular movement.
• 2) Do cover uncover test: • Put the torch in front of patient • Ask the
patient to fix on torch • Cover the fixing eye [* in which corneal light
reflex is central], so the other squinting eye will fix
• Results: • If the new position is maintained, so squint is alternating •
If the original position returns, so squint is unilateral & you should
specify if it is Rt or Lt .

82. How to comment on extra ocular muscles …
Items to comment on in squint :
• 1. Alternalting or Rt or Lt .
• 2. Concomitent (or paralytic) .
• 3. Divergent or convergent .
• 4. apparent Squint.
• 5. Angle of squint.

83. Thank you