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- 1. PHYSICAL EXAM OPHTHALMOLOGY Alejandro | Amihan | Antolo | Araneta | Montalbo 2023 CLMMRH - Department of Ophthalmology
- 2. 01 02 03 04 EOMS TABLE OF CONTENTS VISUAL ACUITY PUPIL EXAM SLIT LAMP
- 4. v VISUAL ACUITY 01 2023 CLMMRH - Department of Ophthalmology
- 5. VISUAL ACUITY ● Measurement of visual acuity provides clinicians with a standard tool for reporting and recording a patient's vision. ● It can be tested either for distance or near, conventionally at 20 ft (6m) and 12-14 in (30- 36 cm) away, respectively. ● Scored as a fraction
- 6. NOTATIONS USED IN RECORDING VISUAL ACUITY VA Visual Acuity OD (Oculus Dexter) Right Eye OS (Oculus Sinister) Left Eye OU (Oculus Uterique) Both Eyes sc Without correction cc With correction ph Pinhole NV Near Vision
- 7. DISTANCE VISUAL ACUITY ● recorded as a ratio or fraction which compares the performance of the patient with an agreed upon standard VA = Distance from the patient to the chart Distance at which normal eye can read the given line
- 8. ALTERNATIVE NOTATIONS FOR RECORDING VISUAL ACUITY
- 9. Visual Acuity is generally tested using the Snellen Chart at a distance of 6 meters or 20 feet. The general steps are as follows: 1. Place patient at the designated distance of 20 feet or 6 meters from a well illuminated Snellen Chart. 2. Always test the poorer eye first. If there are no problems, the right eye is tested and recorded first. 3. Ask the patient to read the chart starting at the biggest letter up to the smallest readable letters 4. Record the acuity measurement by jotting down the numeric designation of the smallest line that the patient was able to read. 5. Occlude the patient’s other eye and repeat steps 3 and 4. 6. If the patient’s visual acuity is less than 20/20 in one or both eyes, repeat the test with the patient viewing the test chart through a pinhole occluder and record these results.
- 10. If the patient cannot see the largest Snellen letter, proceed as follows: 1. Reduce the distance between the patient and the chart until he/she is able to read the 20/200 line. Record this new distance as the numerator of the acuity designation while retaining the denominator. For example, if the patient is able to read the 6/60 (20/200) line at a distance of four meters, the vision is recorded as 4/60. 2. If the patient is unable to see the largest Snellen letter even at a distance of one meter or 3 feet, hold up one hand and ask the patient to count the number of extended fingers. Record the distance at which counting fingers is done accurately. For example, if a patient can count fingers at a distance of ½ meter, visual acuity is recorded as CF at ½ meter. 3. If the patient cannot count fingers, determine whether or not he/she can detect the movement of your hand. Record a positive response as hand motion designated as HM. 4. If the patient can detect hand motion, use a penlight to determine if the direction of the source of the light can be correctly detected by the patient. Shine the light on four quadrants.
- 11. 5. If the patient is unable to correctly identify the direction of the source of the light but is able to detect its presence, record the patient’s response as light perception (LP). If the presence of light can not be detected by the patient, this is recorded as No Light Perception (NLP)
- 12. NEAR VISUAL ACUITY ● Routinely done for patients over 35 years of age ● Done if the patient complaints about their near vision ● Sometimes done for instances when distance testing is difficult or impossible (at patient’s bedside) ● Unlike distance vision testing, near vision is tested with both eyes open ● The standard near vision chart is held at a distance of 12-14 inches or 35 cm. If ● The patient normally wears glasses for reading, he should wear them during testing.
- 13. NEAR VISUAL ACUITY ● Since letter size designations and test distances vary, both size and distance should be recorded ○ EX: J5 at 14 inches, 6 pt at 35 cm ● If a standard near vision card is not available, any printed material such as a telephone book or a newspaper may be substituted. Both the approximate type size read and the distance at which the material was held are recorded.
- 14. NEAR VISUAL ACUITY STEPS IN USING THE JAEGER CHART 1.Check near vision with and without correction. 2. With the patient wearing the habitual corrective lens for near and the near card evenly illuminated, instruct the patient to hold the test card at the distance specified on the card (usually 14 inches). 3. Examine the poorer eye or the eye in complaint. 4. Ask the patient to say each letter or read each word on the line of smallest characters that are legible on the card. 5. Record the acuity value for each eye separately in the patient's chart. 6. Repeat the procedure with the other eye. 7. Repeat the procedure with both eyes viewing the test card 8. Record the binocular acuity achieved. 9. If the patient could not read the largest optotype, place "unable to read Jaeger chart"
- 15. v PUPIL EXAM 02 2023 CLMMRH - Department of Ophthalmology
- 16. PUPIL EXAM ● Composed of three components: a. Assessment of pupil size and shape b. Assessment of pupil reaction to light (Light Reflex Test) c. Assessment the reactions of the pupils to a swinging light (Swinging Flashlight Test)
- 17. ASSESSMENT OF PUPIL SIZE AND SHAPE ● Darken the room and instruct the patient fixate on a distant target ● Shine just enough light onto both eyes and observe the size of the patient’s pupils ○ Normal pupil size ranges from 2-4mm ○ Any asymmetry in pupil size of more than 2 mm is considered abnormal
- 18. ASSESSMENT OF PUPIL REACTION TO LIGHT ● Used to evaluate the integrity the pupillary light reflex pathway ○ Direct Pupillary Reaction ■ Performed by shining a penlight at the patient’s eye ■ Normal response is a brisk constriction of the pupil ○ Consensual Pupillary Reaction ■ Light is directed at one eye while the opposite eye is observed for a reaction ■ Normal response is a brisk constriction of the pupil of the opposite eye
- 19. ASSESSMENT OF THE REACTIONS OF THE PUPILS TO A SWINGING LIGHT ● Performed by shining light on one eye, then swinging it across to the opposite eye ○ This process can be repeated several times, allowing for about one second interval for each swinging ● The normal reaction is for the pupil to constrict slightly and to remain constricted as light shines on it
- 20. v EOMS 03 2023 CLMMRH - Department of Ophthalmology
- 21. TESTING EXTRAOCULAR MOVEMENTS ● Examination of eye movements begins by examining ocular alignment in the primary position (straight gaze); simplest method is to observe the position of the corneal light reflections ○ Performed by instructing the patient to look straight and fixate at a distant object while a light is shone towards both eyes ○ A reflection of light will appear in the cornea of each eye ○ If the eyes are properly aligned, the reflection should appear in the center of the pupil in both eyes - normal finding
- 22. TESTING EXTRAOCULAR MOVEMENTS ● Next is to instruct the patient to follow your finger, a penlight or a small target through the 6 cardinal positions of gaze ● Move the target slowly through the different positions keeping it roughly 14 inches or 35cm from the patient ○ When extraocular muscle (EOM) movement is tested with both eyes open, Version Test ○ When performed one eye at a time, Duction Test ● Ask the patient if double vision is noted at any point ● Also observe if there is any limitation movement or nystagmus
- 23. v SLIT LAMP 04 2023 CLMMRH - Department of Ophthalmology
- 24. SLIT LAMP BIOMICROSCOPE ● Is an ophthalmological instrument that allows stereoscopic examination of ocular tissue under good magnification and illumination ● It is used to visualize and evaluate various tissues and layers eye.
- 25. SLIT LAMP EXAMINATION A slit lamp focuses the height and width of a beam of light for a precise stereoscopic view of the eyelids, conjunctiva, cornea, anterior chamber, iris, lens, and anterior vitreous. With a handheld condensing lens, it can also be used for detailed examination of the retina and macula. It is especially useful for the following: ● Identifying corneal foreign bodies, abrasions, and other corneal disorders ● Measuring depth of the anterior chamber ● Detecting cells (RBCs or WBCs) and flare (evidence of protein) in the anterior chamber ● Identifying the location and degree of lens opacities (cataracts) ● Identifying diseases such as macular degeneration, diabetic eye disease, epiretinal membranes, macular edema, and retinal tears (when using a condensing lens), Tonometry and gonioscopy, which quantifies the iridocorneal angle and requires the use of a special lens, may be done.
- 26. v FUNDOSCOPY 05 2023 CLMMRH - Department of Ophthalmology
- 27. FUNDOSCOPY ● The fundus can be examined by direct ophthalmoscopy using an ophthalmoscope or by indirect (often binocular) methods such as indirect ophthalmoscope
- 28. FUNDOSCOPY ● There are 5 structures that should be observed in a systematic fundus examination: ○ Ocular Media ○ Optic Disc ○ Retinal Vasculature ○ Retinal Background ○ Macular Area
- 29. FUNDOSCOPY Before beginning, ensure that the ophthalmoscope is working properly 1. Check the light source. 2. Make sure that the light source is the largest circle. 3. Adjust the lens setting to 0. 4. When examining the patient’s right eye, hold the direct ophthalmoscope with your right hand and use your right eye to view the patient’s eye. Use the left hand and left eye to examine the patient’s left eye. 5. The patient’s glasses are removed, and, barring large astigmatic refractive errors, examiners prefer to remove their own glasses as well. Contact lenses worn by either the patient or the examiner may however be left in place.
- 30. FUNDOSCOPY To perform direct ophthalmoscopy: 1. The room should be dimly-lit and the patient comfortably seated. 2. The patient should be instructed to focus on a distant target. The patient should also be instructed to maintain their gaze throughout the examination. 3. Set the focusing wheel at 0 and select the large, round, white light. 4. Begin to look at the right eye about 1 foot from the patient. Use your right eye with the ophthalmoscope in your right hand. When you look straight down the patient’s line of sight at the pupil, you will see the red reflex. 5. You may place your free hand on the patient’s lid to keep the eye open, or on the patient’s forehead or shoulder to keep yourself steady. Hold the ophthalmoscope comfortably against the arch of your brow.
- 31. FUNDOSCOPY 6. Slowly come closer to the patient at an angle of about 15° temporal to the patient’s line of sight. Try to keep the pupil in view at all times. Turn the focusing wheel with your index finger to bring the patient’s retina into focus. 7. When a retinal vessel comes into view, follow it as it widens to the optic disc, which lies nasal to the center of the retina. 8. Examine the optic disc, retinal blood vessels, retinal background and macula. 9. Repeat the same procedure for the left eye.
- 32. FUNDOSCOPY
- 33. CREDITS: This presentation template was created by Slidesgo, and includes icons by Flaticon, and infographics & images by Freepik THANKS! Please keep this slide for attribution
Editor's Notes
- Its purpose is to correctly assess the patient’s near and far visual acuity for both eyes
- Pinhole - to correct error of refraction Differences in acuity can often be due to refractive error/refractive blur caused by multiple misfocused rays entering through the pupil & reaching the retina. Refractive Errors: Myopia/ Nearsightedness, Hyperopia/ Farsightedness, Astigmatism
- Visual Acuity is generally tested using the Snellen Chart at a distance of 6 meters or 20 feet. The general steps are as follows: 1. Place patient at the designated distance of 20 feet or 6 meters from a well illuminated Snellen Chart. If the patient has corrective lenses, ask the patient to wear them during the test. 2. Always test the poorer eye first. By convention, if there are no problems, the right eye is tested and recorded first. Have the patient occlude his left eye using an opaque occluder. The palm of the patient’s hand may also be used to occlude the vision in the right eye. 3. Ask the patient to read the chart starting at the 20/200 line proceeding to the smallest line which he/she can distinguish more than half of the letters. 4. Record the acuity measurement by jotting down the numeric designation of the smallest line that the patient was able to read. 5. Occlude the patient’s right eye and repeat steps 3 and 4. 6. If the patient’s visual acuity is less than 20/20 in one or both eyes, repeat the test with the patient viewing the test chart through a pinhole occluder and record these results.
- This is the Binocular Alignment Procedure wherein read 1. Stand in front of the patient and ask the patient to look straight and fixate to a distant object while the light is shone in front of both eyes 2. Examine the primary position first. 3. Check for the corneal reflex (This test can be used with infants) Esotropia - convergent, one eye points inward Exotropia - divergent, one eye points outward OTHER CLINICAL FINDINGS: Esotropia - eye position is convergent; light reflex appears temporal to the pupil in that eye Exotropia - eye position is divergent; light reflex appears more to the nasal side in that eye Primary position - Primary position of the eye is that position from which all other ocular movements are initiated changing the position of eyeball from primary to secondary or tertiary. The primary position has been described by the scobee as that of that position of the eyes in binocular vision when, with the head erect, the object of regard is at infinity. Secondary position - These are the position assumed by the eyes, while looking straight up (supraversion), straight down (infraversion), to the right (dextroversion), and to the left (levoversion). Tertiary position - These described the position assumed by the eyes, when combination of vertical and horizontal movements occur. These include position of the eyes in dextroelevation, dextrodepression, levoelevation, and levodepression.
- The purpose of slit lamp examination of the cornea and anterior segment is to determine the position, depth and size of any abnormality It has Direct illumination - with a diffuse light is used to detect gross abnormalities Scleral scatter - involves decentring the slit beam laterally so that the light is incident on the limbus with the microscope focused centrally. Light is transmitted within the cornea by total internal reflection. A corneal stromal lesion will become illuminated because of forward light scatter. This technique is especially useful to detect subtle stromal haze, or cellular or lipid infiltration. Retroillumination - uses reflected light from the iris or fundus after pupil dilation to illuminate the cornea. This allows the detection of fine epithelial and endothelial changes, such as epithelial cysts, keratic precipitates and small blood vessels. Specular reflection - shows abnormalities of the endothelium such as reduced cell density and guttata. Pseudoguttata probably rep- resent reversible endothelial cell oedema and inflammatory cells beneath the endothelial layer. Is an ophthalmological instrument that allows stereoscopic examination of ocular tissue under good magnification and illumination It consists of three main components: the microscope, the illumination system, and the controls. Additionally, the chin rest, forehead rest, and oculars play key roles in ensuring patient and operator comfort." Before conducting a slit lamp examination, obtaining a comprehensive patient history is essential. This includes inquiring about current eye complaints and relevant medical history. With the slit lamp, you can assess the cornea, conjunctiva, and sclera. Pay close attention to the anterior chamber depth, which can be an indicator of conditions like glaucoma. Detecting abnormalities such as corneal scars and foreign bodies is also within the scope of this examination. Biomicroscopy: The slit lamp is also known as a biomicroscope because it enables the examiner to view living tissues of the eye in real-time. This is crucial for identifying various eye conditions and abnormalities.
- Magnification: The slit lamp incorporates a high-powered microscope, which magnifies the structures within the eye. This allows for a close examination of both the anterior and posterior segments with exceptional detail. Slit Illumination: A narrow, adjustable slit of light is used to illuminate the eye. This slit can be adjusted in width and angle, providing different lighting conditions for a thorough examination. It helps to focus the illumination on specific areas and detect abnormalities. Depth Perception: The ability to alter the angle of the slit beam and adjust the microscope's focus allows for a three-dimensional view of the structures within the eye. This depth perception is vital for assessing the depth and location of any abnormalities. Filters: Some slit lamps are equipped with filters that can be used to enhance the visualization of specific structures, such as blood vessels, corneal abnormalities, or changes in pigmentation. Adjustable Aperture: The examiner can change the size and shape of the aperture to control the amount and direction of light entering the eye. This is particularly useful for detailed examination of different eye structures. Anterior Chamber: 1. Aqueous Humor: The anterior chamber is filled with a clear, watery fluid called the aqueous humor. This fluid provides nutrients and maintains the shape of the cornea and the lens. 2. Cornea: The front surface of the anterior chamber includes the cornea, which is the transparent outermost layer of the eye responsible for refracting light onto the lens. 3. Iris: The colored part of the eye, known as the iris, is located in the anterior chamber. The iris controls the size of the pupil and thereby regulates the amount of light entering the eye. 4. Lens: The crystalline lens separates the anterior chamber from the posterior chamber. It plays a crucial role in focusing incoming light onto the retina. Posterior Chamber: 1. Vitreous Humor: The posterior chamber contains a gel-like substance called the vitreous humor. This clear, jelly-like substance helps maintain the shape of the eye and fills the space between the lens and the retina. 2. Retina: The retina is the light-sensitive layer at the back of the eye in the posterior chamber. It contains photoreceptor cells (rods and cones) that capture light and send visual signals to the brain via the optic nerve. 3. Choroid: The choroid is a layer of blood vessels and connective tissue that lies between the retina and the sclera (the white part of the eye). It provides nourishment to the outer layers of the retina. 4. Optic Nerve: The optic nerve exits the eye from the posterior chamber and carries visual information from the retina to the brain, where it is processed to create our perception of vision.
- Direct illumination - with a diffuse light is used to detect gross abnormalities Scleral scatter - involves decentring the slit beam laterally so that the light is incident on the limbus with the microscope focused centrally. Light is transmitted within the cornea by total internal reflection. A corneal stromal lesion will become illuminated because of forward light scatter. This technique is especially useful to detect subtle stromal haze, or cellular or lipid infiltration. Retroillumination - uses reflected light from the iris or fundus after pupil dilation to illuminate the cornea. This allows the detection of fine epithelial and endothelial changes, such as epithelial cysts, keratic precipitates and small blood vessels. Specular reflection - shows abnormalities of the endothelium such as reduced cell density and guttata. Pseudoguttata probably represent reversible endothelial cell oedema and inflammatory cells beneath the endothelial layer.
- Findings on fundus examination are typically reported in a systematic manner, as follows: -ROR should be evenly colored and is not interrupted by shadows -Normal optic disc will appear slightly oval vertically and yellowish-orange to pink in color; its margins should be sharp or distinct -Arteries usually appear brighter red in color than the veins with a prominent shiny reflex stripe, Caliber of the arteries in comparison to the veins (N: 2:3 4:5) -Retinal background is generally reddish orange in color -for the macula which is located temporal to the optic disk, we should take note of any presence of exudates or hemorrhages that may prevent the appearance of foveal reflex At the center of the macula is a central depression called the fovea which may act as a convex mirror and produce a light reflection known as the foveal reflex. A small pinpoint white reflection or “reflex” marks the central fovea. foveal reflex is a bright pinpoint of light that is observed to move sideways or up and down in response to movement of the opthalmoscope.