Examination technique of the Eye &

Ophthalmic Equipments
 
Examination technique contd…
• Objective:
 General- visual function &ocular health.
 Specific-
Ocular and systemic Sx &Sn
– Determine:
• Optical &health status of the eye
• Visual system and related structures
• Identify risk factors
• Detect ocular abnormalities and diseases
• Establish +/- ocular Sx& Sn
Examination technique contd…
• HISTORY-
• Components
•  demographic data
• CCs &HPI
• Visual status, needs, ocular Sx
• Past ocular Hx
• Eye disease, Dx ,Rx, Surgery, Injury, Medications
• Past Systemic illness
• Medical/Surgical illnesses
• Family Hx
Examination technique contd…
• Ocular Examination

• VA –Distance&Near
• Tonometery/IOP measurement
• Ocular alignment &motility
• Pupil
• External Eye &Ocular adnexa
• Anterior segment
• Posterior segment
 
Ophthalmic Equipments
• Ophthalmic equipments

– Snellen acuity chart

 
Ophthalnic Equipments
• Ophthalmoscopy
• Direct/indirect

• Retinoscope –refractive state

• Keratometer-corneal curvature &diopteric power

• Exophthalmometry

• Standardized color vision plates-color vision

• A scan Ulstarsound

• B Scan Ultrasound
• Visual field analyzer
• Additional supportive diagnostics
– CT Scan
– MRI
Ocular History
• History
– Chief complaints
• Main problems
• Reason for visit
• Other problems
• Patient’s hope following Rx
– Present illness
• Sudden/gradual
• Severity
• Influences
• Constancy/temporal variation
• Laterality
• Documentation-old records/photographs
Ocular symptoms
• Disturbance of vision
• Ocular pain
• Abnormal secrections
• Abnormal appearances
• Trauma
• Others
Ocular Symptoms
• Disturbance of vision
– Blurred/decreased central vision
– Peripheral vision
– Altered image size
– Diplopia
– Floaters
– Photopsias (flashs of light)
– Haloes/rainbow
– Dark daptation
– Color vision
– Blindness
•  
Ocular Symptoms
• Ocular pain
– FB
– Ciliary pain
• With in /around the eye
• Radiating
– Photophobia
– Headache
– Blurring/dryness
– Itching
– Eye strain
 
Ocular Symptoms
• Abnormal secrections
– Lacrimation
– Epiphora
– Dryness
– Discharge
Ocular Symptoms
• Abnormal appearances
• Ptosis
• proptosis
• blepharitis
• redness
• opacity
• strabismnus
 
Ocular Symptoms
• Trauma
– Date, time,place
– What happened
– Safety precautions
– Vision affected
Ocular History
• Past Hx
– Eye glasses
– Ocular medications
• Response to prior Rx
• Dosage, frequency, duration
• Color of the Cap
– Hx of surgery
– Hx of trauma
– Hx amblyopia
 
Ocular History
• General Medical &Surgical Hx 
– Systemic disease
– Preoperative evaluation
– Peadiatric Pts-pregnancy
– Systemic medcations
– Allergies/ Atopy /
– Social Hx
– Family Hx
Ocular examination
• Visual Acuity
– Angular measurement
– Minimal object size resolvable at a specific distance
– Visual angle of 5minutes of arc-20ft(6ms)

• Snellen chart

– Most common
– Numerator (testing distance)&denominator 
 
• Test targets

– Optotypes- letters, numbers, pictures

– Notation-compares size of the optotype to that of 20/20 line

• VA
• CC
• SC
• VOD 
• VOS
• VOU
Ocular Examination
• Testing procedures 
– 1.Distance acuity
• Distance acuity test
– Monocular
– CC/SC
– Occluder
– Familiarity of Pt With optotype
• Pinhole
– single/multiple holes
– Central rays of light
– Improvement by 2 lines/more
– No improvement-high referactive error/other causes
 
 
Ocular Examination
• 2.Near acuity
– Near vision
– Bed ridden/emergency room
– 40 cms
– Decreased –common causes
• Presbyopia
• Uncorrected hyperopia
• Cataract
• Adies Pupil
• Systemic medication

– NPC=6cms-10cms
Ocular Examination
• 3.Testing Children
– Fixation at object
– Following of objects
– Maintenance of steady fixation 
– Newborns-blink response to light
– Ask child’s visual behaviour 
– Cover test 
 
Ocular Examination
• Variables in acuity measurements

– External
• Inconsistent light condition
• Charts contrast
• Charts cleanliness
• Distance B/N projectort &chart
• Sharpness of focus a projected chart
• Glare on the screen
• Crowded optotypes
• Fatigue/bordom
Ocular Examination
• Optical
– Eyeglasses
– Tear film/ocular surface abnormalities
– Media opacity
 
Ocular Examination
• Uncorrectable visual acuity
•  
– WHO  classification
• Moderate visual impairment
• Severe impairment
• Profound /Blindness
– Amblyopia
>2lines difference B/N the two eyes 
– Causes
• Unilateral
– Anisometropia
– Strabisnus
– Opacity 
• Bilateral
– Uncorrected refractive error 
Ocular Examination
• Color Vision
• Perception
• EM energy 400-700
• Absorbed by cone outer segment
• Three photolabile pigments
• blue, green and red sensitive cones
• initiators of color vision
• Contrast Sensitivity
Differential Diagnosis of Ocular Symptoms

 
• Burning sensation
– Blepharitis, Meibominitis
– Conjunctivitis
– inflamed pterigium /pingecula
– episcleritis
– ocular toxicity
 
 
• Decreased vision
1.Transient visual loss=returns to normal
– Causes:
• papilledema
• amaurosis fugax/TIA(transient ischemic attack)
• central retinal vein occlusion
• giant cell arteritis
•  
• 2. Lasting longer than 24hrs
2.1+sudden &painless
– Causes:
• retinal artery /vein occlusion
• vitreous hemorrhage
• retinal detachment
• optic neuritis
• methanol poisoning
2.2 gradual &painless (weeks/mths/years)
– Causes:
• cataract ,refractive error
• open angle glaucoma
• chronic retinal; disease
• chronic corneal disease
 
2.3 sudden &painful
• acute angle closure glaucoma
• optic neuritis
• uveitis, endophthalmitis
• corneal edema
•  
• 3. Posttraumatic
– eyelid swelling,corneal irregularity
– hyphema ,ruptured globe, traumatic
cataract,retinal detachment
– vitreous hemorrhage
• Discharge
– ophthalmia neonatorum
– conjunctivitis 
• Distortion of Vision
– refractive error
– macular disease
– corneal irregularity
• Double vision
– Monocular
• refractive error,
• corneal opacity,
• cataract,dislocated natural lens,
• extrapupillary opening
– binocular-
• Myastenia Gravis,
• cranial nerve III,IV,VI palsies
• orbital disease
• Eyelash loss
– trauma, VKH, Chronic skin disease(leprosy, blepharitis)
• Eyelid crusting-blepharitis, meibominits, conjunctivitis
• Eyelid swelling
– +inflammation-hordeolum, chalazion
– blepharitis/conjunctivitis
– orbital/preseptal celulitis.
– herpes infection
– orbital fat prolapse,
– systemic illnesses
• Lid lag(Lagophthalmos)
– proptosis,
– eyelid scarring,
– CN VII palsy
• Globe protrusion(Proptosis) 
• Flashes of Light
– Retinal break/detachment
– Posterior vitreous detachment
– Migraine 
• Floaters
• Foreign body sensation
– dry eye
– blepharitis
– conjunctivitis
– trichiasis
Examination of External and Anterior segment of the eye

• Inspection
• Palpation
• Auscultaion
• General observation
– lighted room
– brief visual survey
– facial features
– patients attitude, mental status
– overall well being
– apparent nutritional health
– extremities
• Head and face
• Orbit
• Eyelids
• Lacrimal system
• Anterior segment of the globe
 
• Basic equipments
– 1. Illuminators
• room natural light
• pen light/torch light
• direct ophthalmoscope
• +SLM
– Types of illuminations
• Diffuse-day light /torch
• Focal-small beam (pen light), SLM
- tiny defects/opacity
• Coaxial
-same directions of view as rays of light
- gives red reflex
-defects /opacity in ocular media
 
• 2. Magnifiers
– Condensing lens
– Loupes (2x-4x)
– SLM 
• 3 .Measuring devices
Ruler (mm),SLM
 Lesion dimension, lid position
 Intercanthal/interpupillary distance
 Corneal diameter
 exophthalmometer
• 4. Retrators
 cotton tipped applicators/
 metallic instruments(paper clip)
 
• Head and face 
– bones -orbital margin, defects
– muscles- strength-facial palsy
– nerves- sensory/motor supply
– skin- oedema, erythema, vesicles, pustules,
vascular changes
– lymphnodes- preauricular/ submandibular
lypmhadenopathy
– paranasal sinuses-tenderness, sinusitis
• Orbit
– Symmetry &craniofacial development
– trauma, congenital
– Margin
– Frontal bossing
– Tenderness-sinuses/temporal artery
– Lymph nodes
• Intercanthal distance (30mm)
• Interpupillary distance, average=61mm
(distance), near 4mm less
• B/n centers of pupil
• Temporal pupillary border and nasal
pupillary border
• Temporal limbus &nasal limbus
• Globe position/displacement
• exophthalmos
• enophthalmos
• proptosis
– Lateral orbital margin &corneal apex
– Average=17mm
– Difference b/n two eyes=<2mm 
• Pulsations-bruit
• Eyelids
– eyebrows symmetry &relative position
– lifting
– lids position, mvt, symmetry
– upper lid normally covers 1.5mm of cornea
– lid crease
– eye lid opening &closure
– eyelid position relative to cornea
• interpalpebral fissure height
• margin –corneal reflex distance
• upper lid crease position
• levator function
• lid retraction
• eye lid margin apposition in relation to globe
• Examples of abnormalities
– lagophthalmos
– ptosis
– ectropion
– entropion
• Eyelashes
– directions, colour, number, arrangement, deposits
– abnormalities
• trichiasis
• madarosis
• poliosis
• distichiasis
• blepharitis
• Lacrimal sysyem 
– lacrimal gland-palpebral&orbital
– mass, inflammatory signs, tenderness
– puncti-
• apposition to globe/eversion
• opening /patency
– lacrimal sac
• swelling/ erythema
• discharge on digital pressure
•  
• Globe
– Ambient lighting/natural light to see color changes
– Diffuse torch light/pen light/SLM
– Hold eyelid open, cotton applicator
– Tear meniscus-volume, triangular along the
posterior margin
– Wetness -glistening
– Break up time
• Conjunctiva
– discharge, granulomas, scarring, membranes, FB
– Bulbar-vessels ,hges, chemosis, epithelial defects
– Palpebral
• follicles
• papillae
• FB
– Limbus
• Circum corneal injection-radial, red violaceous
• Papillae- gelatinous
• Trantas dots
• Follicles
– Fleshy growth
• Episclera/sclera
– vessels (blanching/not)
– vascular congestion, violaceous
– +/- tenderness
• Cornea
– pen light/SLM
– clarity, ulcer, scars/opacity
– blood vessels
– thickness/oedema
– sensation
– diameter(new born 10mm,adult 11-12mm)
– horizontal Vs vertical
– shape/ curvature
• patient’s side
• along iris plane-ectasia
• lower lid contour-Munson’s sign 
 
• Anterior chamber
– depth- relative position of anterior iris &posterior
cornea
– methods
• flash light with diffuse beam-iris shadow
• flash light with SLM(corneal thickness in relation to A/C
depth)
• gonioscopy
• clarity- optically clear
• inflammatory cells, protein, blood/hyphema, hypopion, FB
• microfilariae
• Iris
– surface, color, vessels, adhesions, mass
• Pupil
• ambient light
– margin, shape, adhesion,
– size
– amount of light, age, drugs, disease, emotion
– anisocoria-size difference
– physiological/essential=<1mm
– true>1mm,+/-ptosis
– reflex
– near-near target
– accommodation, convergence, miosis
– light reflex=direct &consensual reflex
– light reflex pathway
• efferent &afferent
• relative afferent papillary defect
• both pupils equal in size
• swinging light test
• non affected pupil=brisk Rxn
• affected pupil=brisk Rxn when light put on non affected
pupil
• affected pupil no Rxn when light put on it
• efferent pupillary defect
• unequal pupils
• paralysed iris muscle
• Lens
– capsule ,cortex, nucleus
– pupillary dilation-enhance detail of evaluation
– clarity
– position
– size
– 
• Anterior vitreous
– inflammatory cells
– clarity