4. Gross Examination
Things you can see when they walk in the door
Redness
◦ How red is it and Where on the eye is it
Pain
◦ Blepharospasm (squinting)
◦ Rubbing/Pawing at face
◦ Depressed mentation
Position of eyelids (3rd eyelid too)
Discharge
◦ Quantity, color, character
Strabismus, nystagmus
Pupil Assessment
Globe symmetry, shape and size
◦ Buphthalmos, exophthalmos, enophthalmos
Vision
◦ How many things did they bump into on the way to the room
6. Basic Ophtho History: Ocular
Chief Complaint
Signs of discomfort
◦ Rubbing, pawing, squinting
◦ Flinching when approached
◦ Resistance to mouth opening, aggression
Vision changes
◦ Bumping into things
◦ Can’t see toys/treats
◦ Getting lost or disoriented
◦ Poor or well lit area
Duration of problem
◦ When were signs first noted
◦ Stable, progressive, Off & On
Changes in appearance
◦ Redness (Where)
◦ Cloudiness (Where)
◦ Discharge
(quantity/quality)
7. Basic Ophtho History: Systemic
General medical history
◦ Systemic Disease
Diabetes
Cardiac (blood pressure)
Cushings, Thyroid, etc
◦ Systemic Medications
Steroids, Baytril, etc
History of trauma
◦ Needs to be a definite event
◦ Trauma rarely the real cause
Family History
◦ Sometimes useful
Travel History
◦ Out of Northeast
◦ Especially for uveitis
8. Tools for the exam
VERY dark room
Light source- bright focused beam
◦ Finhoff transilluminator is best
Pair of magnifying loupes
Direct ophthalmoscope
Schirmer tear test strips
Fluorescein stain
Tonometer
◦ Not a Schiotz
Proparacaine and Tropicamide
Eye wash
Cotton balls or a laser to test vision
9. One of the most
important things is a
dark room.
This is a picture of how
dark your room should
be.
10. Basic Ocular Diagnostic Tests
Think TPR…
◦ Basic health status for the body, right?
◦ You TPR every case that comes in, right?
The TPR for the eye is:
◦ Schirmer Tear Test
◦ Tonometry for glaucoma
◦ Stain for corneal health
These are simple practice building, money making tests that the
LVT is more than capable of doing
We should be doing an “Ocular TPR” for every pet that comes in
with an eye problem
11. Schirmer Tear Test (STT)
BEFORE YOU DO ANYTHING ELSE!!
◦ This test should be done FIRST
◦ DO NOT apply any solutions/ointments to eye or flush out any
debris prior to test.
◦ Mucous can be removed with dry gauze to allow access to
eyelids
◦ DO NOT perform test on a ruptured cornea, descemetocele or
melting ulcer… but you should still do the healthy eye
◦ Corneal irritation can increase tear production
12. Schirmer Tear Test
Always Measure BOTH EYES
Don’t touch any part of test strips other than the very end (oils on fingers can alter
readings)
Hook curved end of strip over middle to lateral third of lower lid (between third eyelid
and lower lid)
Hold strip in place for 60 seconds
◦ If unable to hold in for full 60sec, stop and record mm/30 sec or # of seconds
held in eyelids
◦ Quickly replace and adjust time if strip falls out
◦ Starting over will decrease overall tear measurement
Immediately record where the line of moisture ends on strip
◦ STT I (before proparacaine)
Measures basal and reflexive tear production
Normal dog ~20 mm/min (prefer >25mm)
Normal cat 3-35 mm/min (Really not that useful in cats)
◦ STT II (after proparacaine)
Measures basal tear production only
Really only used academically
13.
14. Tonometry
Should be performed on EVERY PATIENT with a presenting ocular
complaint (unless perforated or melting)
Always measure BOTH EYES
Normal ~ 10-20 mmHg
◦ Low may indicate uveitis
(but not always)
◦ High (>20-25mmHg) is glaucoma
May not be clinical
TonoPen and TonoVet are two most accepted instruments
Other Instruments, Less commonly used
Cannot obtain artificially low measurement, but can produce
artificially high measurements very easily
Proper restraint is crucial for accurate results
15. Applanation Tonometry
Tono-Pen Vet or Tono-Pen Avia (ergonomic)
IOP determined by measuring the force required to
flatten a given area of the cornea
Requires topical anesthesia
16. Calibration of Tono-pen
Should be calibrated every 1-2wks
Without cover, spray canned air in all the holes on tip of Tonopen
Allow to warm to room temp (5-10min)
Hold nose towards floor with Tonopen cover on
Push black button twice quickly until Tonopen reads “CAL”
Wait for Tonopen to read “UP”
Flip 180° (nose towards ceiling)
Repeat calibration until Tonopen reads “Good”
Holding your hands as steady as possible helps this process to go
smoothly. Sometimes it will get stuck in “calibrate” mode. If this
occurs, either push the button until it snaps out of it, or if you can,
just set it down and come back to it in ~10min.
18. IOP Measurement
Apply topical anesthetic
Sanitary latex cover placed over tip
◦ Make sure it is stretched enough to cover tip but not so much that it
alters IOP readings
Press black button once, double hyphen will appear
Tonometer tip must be directly perpendicular to corneal surface
◦ Try to measure clear, smooth cornea when possible
Gently “tap” on the corneal surface
◦ Audible “chirp” is heard for each acceptable reading
Average of measurements calculated internally
◦ Audible “beep” is heard
◦ Error percentage displayed
< 5% - preferred
< 10% - acceptable
20% and over - unacceptable
19. IOP Measurement
Proper Restraint
◦ No pressure around neck
◦ Very minimal eyelid manipulation
◦ Light pressure on boney areas of head
Proper Position
◦ Sternal Position Preferred
◦ Nose parallel to floor, looking straight forward
25. Manipulation IOP over
Lateral eyelid extension with both jugular veins
compressed
+ 17.6 mm Hg
Lateral lid extension + 16.5 mm Hg
Dorsoventral lid extension + 6.4 mm Hg
Manual compression of both jug veins + 3.0 mm Hg
Manual compression of ipsilateral jug vein only + 0.3 mm Hg
Baseline - minimal eyelid
restraint
Maximal ventral and
dorsal extension of lids
Lateral lid extension
Klein et al, JAVMA 2011
26. Fluorescein Stain
Corneal stroma will retain stain
Corneal epithelium and descemet’s membrane will not
Use individual strips to prevent bacterial contamination
Stain pattern and uptake vary depending on type of corneal
ulcer/disease
◦ Glaucoma can actually cause a diffuse patchy stain uptake
Important to always check IOP!
ULCER DOES NOT = TRAUMA
Other uses
◦ Jones test – assess nasolacrimal duct patency
◦ Tear film break up time (TFBUT)
27. Fluorescein Stain
Wet end of strip with sterile eye wash solution (water
or Proparacaine doesn’t activate Fluorescein
molecules as well)
Apply stain to conjunctiva or sclera
◦ DON’T TOUCH CORNEA WITH STRIP
Flush out excess stain with sterile eye wash
Alternatively: remove plunger on 3cc syringe, insert
fluorescein strip and fill with sterile eye wash, leave
enough room for plunger to be reinserted. Use 1-2
drops in each eye
This syringe must be discarded at the end of each
day
28.
29. Bacterial Culture and Sensitivity
Ideally done after STT and before anything else
Topical anesthetic can be used so it will not hurt and its use will
not interfere with results
Keep in mind the eye is swimming in bacteria normally so
this may not be all that useful
Mucoid discharge does not equal an infection, no matter
what color it is. It might, but usually not.
33. Ophtho Terminology
Anisocoria (an-ahy-suh-kawr-ee-uh)- pupils are different sizes
Blepharospasm (blef-er-uh-spaz-uh m)- spasm of the orbicularis oculi
muscle resulting in eyelid closure (squinting)
Buphthalmos (buph·thal·mos)- enlargement of the eye due to glaucoma
Canthus (Medial and Lateral)- corners where upper and lower lids meet
Cataract- opacity of the lens: congenital, age, disease, trauma
Chemosis- conjunctival edema
Descemetocele (děs'ə-mět'ə-sēl‘)- deep corneal ulcer with exposure of
basement membrane of the corneal endothelium, 1 cell layer left
Distichia (dis-tick-e-uh)- extra hairs along the lid margin
Ectopic Cilia – hairs growing through the congunctiva toward cornea
Ectropion- rolling out of eyelids
Entropion- rolling in of eyelids
Enophthalmos- abnormal “sunken” position of the globe within orbit
34. Terminology
Enucleation- Eye removal
Epiphora (ih-pif-er-uh)- overflow of tears
Episcleritis- inflammation of the connective tissue immediately exterior
the sclera
Exophthalmos- abnormal “protruding” position of the globe from orbit
Hyalitis- evidence of inflammation within the vitreous body
Hyphema- blood in the anterior chamber
Hypopyon- white blood cells in the anterior chamber (often a white blob
that settles at base of anterior chamber
Keratitis- inflammation of the cornea
Lagophthalmos- incomplete eyelid closure to cover eye
Microphthalmos- small eye - congenital
Miosis- pupil constriction
Mydriasis- pupil dilation
Nystagmus- abnormal eye movement, often continuous
Phthisis Bulbi- “shrunken” globe due to disease process
36. Pupil Assessment
Size
Shape
◦ Dysoria
◦ Normal
Dog: round pupil
Domestic Cat: vertical slit
◦ Generally pupils all have
a round shape when
dilated
Symmetry
◦ Anisocoria
Position
◦ Corectopia
Reaction to light
◦ Direct and indirect PLR’s
37. Orbit
Palpate orbital bones
◦ Lacrimal, zygomatic, frontal, sphenoid, palatine,
maxillary
Exophthalmos vs enophthamos vs
buphthalmos
Jaw opening
◦ Pain or resistance to
jaw opening
42. Neurophthalmic Exam
Neurologic responses/reflex
◦ Menace response
◦ Palpebral reflex
Lateral, medial, ventral, dorsal stimulation
◦ Dazzle reflex
◦ Direct and indirect pupillary light reflexes
(PLR)
Extent and speed of PLR
43. Examination of Anterior Segment
Ideally performed in
dim or ambient
lighting
◦ Magnifying loupes
◦ Finoff transilluminator
Can be put on a direct
ophthalmoscope
Preferred to pen light
Brighter and more
focused light beam
◦ Slit lamp used by
Ophthalmologists
Higher magnification
Stronger light source
Variable slit widths etc
44. Third Eyelid
Elevate by gently pressing on the
globe through the upper eyelid
◦ DO NOT PERFORM IF RISK OF
GLOBE PERFORATION
Location at rest
◦ Ddx if elevated at rest
Orbital disease, Horner’s, Phthsis bulbi,
retraction of globe due to pain, etc
Leading edge
◦ Check for ulceration, masses,
hyperemia, depigmentation,
thickening
45. Third Eyelid
Gland of the third eyelid
◦ Prolapse of the gland of the third eyelid
“Cherry eye”
47. Third Eyelid
Cartilage of the third eyelid
◦ Scrolled “T” cartilage or tips
◦ Inversion vs eversion
Changes in color
◦ Hyperpigmentation, hyperemia,
depigmentation
Irregularities of surface or margin
◦ Pannus, KCS, follicles
◦ May indicate chronicity
http://davidlwilliams.org.uk/wp-
content/uploads/archivesite/pic258.jpg
48. Third Eyelid
Foreign bodies
◦ Always evaluate under the third eyelid for
any foreign material
49. Conjunctiva
Palpebral vs bulbar
http://www.enpevet.de/Lexicon/GetMedia.aspx?mediaid=f06a3219-4630-11df-874a-73f5125785b0
50. Conjunctiva
Changes in color
◦ Hyperemia, pigmentation, anemia, icterus
Discharge
◦ Mucopurulent, mucoid, serous, purulent,
dried or crusted exudate
Subconjunctival hemorrhage,
emphysema
52. Nasolacrimal System
Only visible portions = upper and lower
puncta
Clinical signs of disease
◦ Epiphora, mucoid mucopurulent or
mucohemorrhagic discharge
Jones test
◦ Assessment of fluorescein dye passage through
to nostrils
Dacryocystitis
◦ Dermatitis or blepharitis, generally at the medial
canthus
◦ Swelling or abscessation near medial canthus
Punctal occlusion vs ductal occlusion
55. Cornea
Change in color
◦ Blue: edema
◦ Red: vascularization
Determine if deep or
superficial
◦ Yellow: infiltrate
Highly suggestive of
infection
56. Cornea
Change in color
◦ Brown: pigmentation
Indicates chronicity
◦ White: scar, leukoma,
lipid, calcium etc
57. Cornea
Change in contour
◦ Keratoconus
◦ Deep
ulcers/descemetoceles
◦ Masses/nodules
elevated from surface
Granulation tissue
Neoplasia
Raised scar or pigment
◦ Protrusion of tissue
from the surface
Iris prolapse
Bulging descemetocele
58. Sclera
Only the anterior portion
is visible on exam
◦ Visualized through the
thin bulbar conjunctiva
Thinning
◦ Staphyloma, buphthalmos
◦ Underlying choroid visible
(pigmented)
Scleral nodules
◦ Below conjunctival
surface
Can see freely moveable
conjunctiva above nodules
59. Sclera
Scleral rupture
◦ Change in contour: generally
due to globe rupture at limbus
◦ Usually a history of trauma
◦ Pigment or masslike
protrusion
Inflammation
◦ Increased redness, scleral or
episcleral injection
◦ Tortuous or engorged blood
vessels
Pigment changes
◦ Melanosis, neoplasia
Peterson-Jones VO 200
60. Anterior Chamber
Space between the
iris and posterior
cornea
◦ Filled with aqueous
humor
Assess globe from
the side
◦ Easiest to view from
the lateral aspect
61. Anterior Chamber
Clarity
◦ If view of the iris face is not clear, consider anterior chamber
debris vs decreased corneal clarity
Depth
◦ Increased
Posterior lens luxation, microphakia, buphthalmos, post-cataract surgery
◦ Decreased
Anterior lens luxation, aqueous misdirection glaucoma, iris or ciliary body
tumors, cysts, iris bombe, intumescent cataract
63. Iris and Pupil
Evaluate pre and post-
dilation
◦ Iris face better visualized
pre dilation
◦ Posterior iris and ciliary
body better visualized
post dilation
Altered shape (dyscoria)
or position (corectopia)
◦ Anterior or posterior
synechiae
◦ More than one aperture
Iris coloboma, persistent
pupillary membranes, iris
atrophy, iris hypoplasia
64. Iris and Pupil
Altered iris color
◦ Iris rubiosis, hyper or hypopigmentation,
neoplasia, abscess, uveitis,
heterochromia irides
69. Superficial Corneal Ulcer
Ulcer confined to loss of corneal
epithelium
◦ Fluorescein stain positive
Not obviously infected
◦ No infiltrate, mild if any corneal
edema
◦ +/- neovascularization
Broad spectrum antibiotic
coverage
◦ Neopolybac ointment, tobramycin
solution
Consider atropine depending on
degree of discomfort
Recheck in 2-3 days to ensure
ulcer is not progressing in depth
70. Deep Corneal Ulcer
Any stromal loss present
◦ Visible divot or depression of corneal surface
Culture and cytology samples should be taken
prior to any irrigation or fluorescein staining
Topical fluoroquinolone
◦ Ofloxacin penetrates intact corneal epithelium,
ciprofloxacin does not
Topical atropine
◦ Caution in small patients
◦ Use ointment in cats
Do not use any ointments if eye is at risk for or
has perforated
Oral antibiotics, oral anti-inflammatories
Discuss referral as ulcers of any stromal depth
can progress to perforation in a matter of hours
◦ If declined, recheck in 1-2 days to ensure depth is
not progressing
71. Keratoconjunctivitis Sicca (KCS)
Irrigation of globe 2x daily to remove
debris
Topical lacrostiumulant
◦ Cyclosporine
Optiummune = cyclosporine 0.2%
Also available in 1% or 2%
◦ Tacrolimus 0.03%
Topical antibiotic or antibiotic/steroid
combination
◦ Neopolybac if concurrent corneal
ulceration
◦ Neopolydex if no corneal ulceration
Topical lubricants
◦ Optixcare gel, Genteal severe gel
◦ Apply as often as required for lubrication
72. Glaucoma
Immediate referral as permanent
blindness occurs within hours of
elevated IOP
Primary glaucoma
◦ Cosopt (dorzolamide 2%/timolol 0.5%)
q 8 hours
◦ Latanoprost q 12 hours
◦ +/- Mannitol
◦ +/- Aqueouscentesis
Secondary glaucoma
◦ Treat underlying cause of glaucoma
◦ Cosopt (dorzolamide 2%/timolol 0.5%)
q 8 hours
◦ Latanoprost q 12 hours
DO NOT USE IF GLAUCOMA IS
SECONDARY TO LENS LUXATION
73. Uveitis
Clinical signs
◦ Episcleral injection, miosis, aqueous cell or flare,
blepharospasm, iris rubiosis, corneal edema, ocular
hypotension
◦ Hyphema, hypopyon
Screening diagnostics
◦ CBC/Chem/UA/T4
◦ Infectious disease titers – dependent on geographic location
Treatment
◦ Topical anti-inflammatories
Neopolydex, pred acetate
Ensure fluoroscein stain negative prior to initiating treatment with a
topical steroid
◦ Topical cycloplegic – atropine
◦ Oral anti-inflammatories
◦ Oral antibiotics
If no improvement within 24 hours or if IOP is elevated
(secondary glaucoma) refer for evaluation
74. Blindness
Acute vision loss
◦ Immediate referral for best chance for definitive diagnosis and possible restoration of vision
Optic neuritis
◦ Oral immunosuppressives are most effective when given early in the course of disease
Retinal detachments
◦ Exudative, rhegmatogenous, dialysis/disinsertion
◦ Cats: most common cause is hypertension
Exudative or bullous retinal detachments
Check systolic blood pressure on all cats with the presenting complaint of blindness or vision changes
Drug induced retinopathy
Specific retinopathies
◦ Immune mediated – VKH, IMTP, IMHA, Systemic lupus
◦ SARDS vs IMR
Infectious retinopathy – dependent on geographic location
Retinal degeneration
◦ PRA or other inherited retinopathies
◦ Secondary to glaucoma
Editor's Notes
Anatomy is crucial as accurate localization of the problem helps narrow your differential list. Will also help the ophthalmologist guide you via phone calls or photos
As with all diseases, a thorough history will provide crucial guidance toward an accurate diagnosis.