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Question 1

What do you inspect in the eye ?

Answer 1

Symmetry
- corneal light reflex
Abnormality in the eyelid
Palpebral fissure
- shape, size, symmetry
Sclera :
- clarity of sclera
- hyperaemia
Clearness of cornea and pupil
Conjunctiva
- color : too pale => anaemia, diabetes
- discharge
- clarity

Question 2

What do you inspect in the eyelids ?

Answer 2

Skin : swelling, discoloration, tumor, eyelashes
Alignment :
- symmetrical
- droop
- turn inward or upward

Is the eye completely covered when it closes ?
- lagophthalmos can cause dehydration of cornea : proptosis, enophthalmos

Relation to the cornea :
-upper eyelid should be 1-5 mm over the cornea
- lower eyelids should touch the cornea at 6 o’clock

Question 3

Inspection of the pupils ?

Answer 3

Pupils constricted ==> drink
Pupils dilated ==> ADHD medication.
Should be round

Question 4

Inspection of the cornea

Answer 4

Should be shiny and transparent.
Redness
- local : subconjunctival hemorrhage
- diffuse : hyperaemia
— peripheral of cornea : uveitis
— everywhere : infectious or allergic

Question 5

Technique of pupillary response test ?

Answer 5

Subdued light. Sitting opposite to each other. Ask patient to look at point in the distance.

Shine light straight into one eye (block other eye from the light).
- direct pupillary response
- indirect pupillary response

Pupillary response to convergence :
- patient watch finger while it move towards them
- both pupil contract

Question 6

Relative afferent pupil defect ?

Answer 6

The affected eye does not show direct pupillary response
The unaffected eye does not show indirect pupillary response

Question 7

Technique of corneal light reflex ?

Answer 7

= ocular alignment
Shine penlight at both eye from a distance of 50 cm. Reflection of the light should be symmetrical.

Question 8

Diplopia examination ?

Answer 8

Ask patient to follow your finger while you move it to the sides. Observe when they tell you they can see one / two images.

Does it disappear when they cover one eye ?
- binocular (only with 2 eyes open) : loss of cranial nerve, abnormality of the eye muscle, displacement of the eyeball
- monocular (with one eye open) : refractive error, cataract

Question 9

Technique of visual field measuring ?

Answer 9

Donder test : peripheral vision field

Amsler test : central visual field
- patient fix their gaze on a dot in the middle of the grid and describe where the scotoma are

Question 10

Type of scotoma ?

Answer 10

Scotoma : visual field abnormality or blind spot

Central scotoma : central part of visual field may be lost as well as visual acuity

Paracentral scotoma : visual acuity normal, loss of vision field around the center

Question 11

Measuring intraocular pressure ?

Answer 11

Subtle change in intraocular pressure need proper equipment.

Severe change : detected using palpation with both index on closed eyelids and compare
- normal : firm and elastic
- acute glaucoma : hard eye, severe pain and nausea

Question 12

What are the test on indication ?

Answer 12

Visual acuity :
- optotype test
- pinhole occluder
Fluorescent staining
Fundoscopy : to examine the retina

Question 13

What is visual acuity ?

Answer 13

Ratio between distance at which the eye is able to discriminate a particular optotype and the distance at which a normal eye can.
Relative measure, expressed in decimal in the Netherlands.

Question 14

Vocabulary of eye prescription :

Answer 14

OD : right eye
OS : left eye
OU : both eyes
Negative number : myopia
Positive number : hyperopia
Positive lens : converging ray = convexe lens
Negative lens : diverging ray = concave lens

Question 15

Technique of optotype testing ?

Answer 15

Patient 6 meters away from the snelle chart. Looking at it in a relax way. Stop examination when they have 3 bad in a row. Last row they can see is their visual acuity.

If they cannot see anything at 6 meter then do the finger test instead. If they still can’t see ask them to step one meter forward.

Question 16

Effect of the pinhole occluder ?

Answer 16

If patient can’t see the snelle chart you can make them wear the pinhole occluder.
The sharp narrowing a light beam make eye refraction less important to have sharp projection on the retina. It reduces the effect of refractive error and media opacification.
- visual acuity improve : refractive error
- visual acuity does not improve : problem on the retina or at the nerve

Question 17

Technique of corneal fluorescent staining ?

Answer 17

Hold up fluorescent strip against conjunctiva after moistening it with drop of water.
Shine blue into the eye. Damage of the epithelium will shine green.

To identify superficial corneal injury caused by damage to the corneal epithelium.

Question 18

Red flags of vision loss :

Answer 18

Flashes and floaters : retinal detachment or tear

Acute diplopia : compression of the nerve, ischemia of the eye

Loss of part of visual field

Temporary visual loss in one eye : insufficiënt blood supply to the retina => amaurosis fugax

Acute visual loss : retinal detachment, trauma, vascular occlusion

Question 19

Red flag of a red eye ?

Answer 19

Pain
Photophobia
Nausea, vomiting
Reduced visual acuity

Question 20

Type of eyelid disorder ?

Answer 20

Blepharitis : chronic inflammation of eyelids
- red and swollen, skin flakes, yellowish discharge
- associated with seborrhoiec dermatitis, eczema, rosacea

Localised swelling : chalazion = inflamed granuloma originating from blocked meibomian gland duct
- acute : red, painful
- after : hard, painless

Malignant tumor : firm painless lesion

Question 21

Palpebral fissure abnormality :

Answer 21

Ptosis :
-neurological cause (loss of CN3, Horner’s syndrome)
- myasthenia gravis
- mechanical cause (aging of levator palpebrae muscle, prolonged contact lens use)

Entropion or ectropion : aging, facial palsy, scarring

Question 22

Abnormality of eyeball ?

Answer 22

Proptosis = exophthalmos
- tumor in the eye socket, inflamed tissue

Sunken eye = enophthalmos
- fracture of orbital floor/wall

Question 23

Abnormality of the cornea ?

Answer 23

Haziness : dehydratation
- irritation, bruning, blurred vision, lacrymation

Local clouding : scars or infections

Damage to corneal epithelium by foreign object
- gritty sensation

Arcus senilitis : circular whiteish discoloration parallel to corneal margin
- common and harmless in elderly

Disorder seen using fluorescence.

Question 24

Abnormality seen on fluorescence ?

Answer 24

Abrasion of cornea when scratched by sharp object.

Whitish lesion : cornea infiltrate
- serious infection of corneal stroma

Staining looking like tree = dendritic lesion
- herpes simplex virus : herpes keratitis

Question 25

Redness in the sclera = hyperaemia ?

Answer 25

Deep red discoloration of nasal or temporal segment : subconjunctival hemorrhage
- harmless, no visible blood vessel

Diffuse redness with increased vascularisation : conjunctivitis
- bacterial : with pus, eyelids stuck together
- viral : worse hyperaemia with lacrimation, subtle bump on conjunctiva. Can be caused by adenovirus => highly infectious

Others causes :
- keratitis
- intraocular inflammation : uveitis, iridocyclitis

Question 26

Abnormality of the anterior chamber ?

Answer 26

Clouding => always pathological

Severe inflammation : leukocyte form whiteish mirror in the anterior chamber
- hypopyon

Precipitation of red blood cell in anterior chamber
- hyphaema