4. • Eye is most ACCESSIBLE to DIRECT EXAMINATION
• External Anatomy is visible to INSPECTION
• Interior eye examined with advanced instruments
• Visual function can be QUANTIFIED
• The Eye is the ONLY body part where Blood
Vessels and Nervous system tissues can be viewed
directly
5. Visual Abnormalities
• ANYWHERE Along the Eye
• Anterior (Adnexa, Cornea) to Posterior (Neurologic)
• Central Acuity vs Peripheral Vision
• Duration
• Transient, Acute or Chronic/Prolonged
• Degree of Visual Loss
• Visual Aberrations
• Glare and Halos
• Distortions
• Floaters
• Flashes of light
• Diplopia
6. Appearance
• RED EYE
• Other color abnormalities
• Jaundice, Pigmentation, Opacities
• Lesions
• Tumors
• Inflammation
• Deformities
• Displacements
10. VISION
• Vital Sign
• Measured in EVERY Ocular exam
• Whether w/ Glasses or not
• Quantified by Visual Acuity and Visual Fields
• Subjective - requires Patient Response
• Good Vision
• Intact Neurologic pathway
• Structurally Healthy eye
• Proper Focus
11. Visual Acuity
• A measurement of the smallest object a person can identify at a given
distance
• Tested for Far and Near
• Oculus Dexter (OD) – Right eye
• Oculus Sinister (OS) – Left eye
• Oculus Uterque (OU) – both eyes
• SC – Uncorrected visual acuity
• CC – Corrected acuity
13. • Numerator = represents distance between Patient and eye Chart
• Denominator = distance of the smallest row of letters that the Patient can read; distance at which a
person w/ Normal VA can read letters
Visual Acuity
• Recorded as a Fraction
• Compares patient’s performance with an agreed upon standard
20/50 20/70 20/200 10/200 5/200
• Numerator
• Denominator
15. Visual Acuity
• Test one eye at a time !
• By convention, OD first
• Read the smallest line w/ more than
half letters/optotypes distinguished
• If VA 20/30 or less, do Pinhole
• Test w/ and w/o glasses
16. Pinhole
• Estimates Corrected VA
• Prevents misfocused light rays from
entering the eye
• Only centrally aligned focused rays
reach the retina
• Resulting in a sharper image
17.
18. Visual Acuity
If Patient CAN’T see largest letter
• Reduce testing distance.
• Record new distance as Numerator
• Unable to read at 3 ft, test by
Counting Fingers; record as CF
• Cant do CF? Test for Hand Motion (HM)
• No HM? Test for Light Perception and
Projection.
21. OD
VA sc 20/25
cc 20/20
VA CF
VA LP w/ good projection
OS
VA sc 20/50 ! 20/30 by PH
cc 20/40 ! 20/20 by PH
VA sc 20/40 ! NIPH
VA 15/200 ! 20/100
22. Near Distance
• Performed if
• Patient has complaint about near vision
• Distance testing is difficult or impossible (i.e bedside)
• Testing distance of 14-16 inches (35-40 cm)
• Test one eye at a time!
• Use spectacles, NO Pinhole
• Noted as JAEGER NOTATION
I
II
23. OD
VA sc 20/25 , J10
cc 20/20, J7
VA CF , J II (?)
OS
VA sc 20/50 ! 20/25 by PH , J1
cc 20/20 , J1+
VA HM
24. VA in Children
• Can be difficult, uncooperative
Newborn
• Corneal Light reflex
• Pupillary testing
• Red reflex, Fundus examination
Infants – 2 y.o
• Assess visual function instead of acuity
• CSM , fixates and follows
2-5 y.o
• Test visual acuity , may not reach 20/20
• As long as VA equal in both eyes; 20/40 – 20/50
25. VA in Children
• Non-verbal or Pre-verbal Children
• CSM Method
• Central – centrality of corneal light reflex
• Steady – steadiness of eye, nystagmus
• Maintained – maintain fixation after removal of occlusion
27. Confrontation Visual Field
• Grossly examines for any significant Visual Field Defects
• 1 meter or 1 arms length from px
• Cover one eye of px , examiner covers opposite eye
• Maintain fixation on eyes
• Use CF instead of finger movement
• Test 4 quadrants
30. • General examination of the Adnexa
• Eyelids
• Globe
• Orbit
• Lymph nodes, Sinuses, Skin
• Performed before evaluating the eye under magnification
• Gross Inspection and Palpation
• Lesions
• Inflammation
• Malposition, Asymmetry
31. Adnexa
• PENLIGHT is an important tool
• External Inspection
• Eyelids, surrounding tissues and palpebral fissure
• Palpation
• Conjunctiva and sclera
• Upper Eyelid Eversion
• Search for FB or conjunctival signs
• Topical anesthesia helps facilitate examination
32.
33. Adnexa
Pupillary Reaction Testing
• Size and shape assessed
• Direct and Consensual Reflex
• Relative Afferent Pupillary Defect (RAPD)!!!
• May reveal indications of neurologic disease
34. Adnexa
AC Depth Assessment
• Normally AC is deep and Iris w/ flat contour
• When AC is shallow, Iris is bent forward
• Nasal Iris is seen in a shadow when light is directed from temporal side
• Torchlight method
44. Tonometry
• Intraocular pressure (IOP) measurement
• Normal = 10-21 mmHg
• Gold Standard = Goldmann Applanation Tonometry
• Digital Tonometry – estimates IOP
45.
46. Tonometry
Digital Tonometry Technique
• Instruct the patient to look down (NOT close
the eyes)
• Alternately palpate/indent the globe through
the upper eyelid using one index finger
• Feel for the rebound pressure with the other
index finger.
47. Tonometry
• Recording findings
• OD = firm
• OS = firm
• Normal: soft-firm (tip of nose)
• Abnormal: hypotonic (ear lobe/lips) = LOW IOP ! Retinal Detachment,
Trauma
• Abnormal: hard (forehead) = HIGH IOP ! Glaucoma
48. Ocular Motility Testing
• Follow an object in 6 directions, the Cardinal Fields of gaze
• Enables to test each muscle in its primary action
53. Funduscopy
• Objective: to visualize the Optic Nerve Head and the Retinal structures
in the posterior pole of the fundus
54.
55. Funduscopy
Technique:
• Px’s OD ! MD’s OD / right hand
• Px’s OS ! MD’s OS / left hand
• Remember: right-right-right / left-left-left
• Dim / Dark room (increase Mydriasis)
• Instruct px to look far away (avoid Miosis)
