Clinical Skills

Question 1

To examine a patients right eye with an ophthalmoscope what hand and eye should be used?

Answer 1

Right eye, right hand and right fore-finger on dial of ophthalmoscope should be used to examine the patient’s R eye, and vice versa for left. Keep top of ophthalmoscope close to observer’s brow such that the ophthalmoscope aperture is close to the eye.

Question 2

Describe 3 things look at in ophthalmoscope exam?

Answer 2

Look for red reflex in 0 lens (arms length away)
Look at anterior of eye with + 10 lens (v close)
Dial down to zero to look at the back of the eye (v close)

Question 3

Define a squint

Answer 3

A squint is the term used when the two eyes are not pointing in the same direction. This means they are not working together as a pair. One eye may turn either inwards, outwards, downwards or upwards, whilst the other eye looks straight at the target of interest.

Question 4

Define a manifest squint

Answer 4

Manifest squintis present when the eyes are open and being used

Question 5

What is the purpose of a cover test?

Answer 5

To detect a manifest squint

Question 6

Corneal reflections will be _________ in a manifest squint

Answer 6

asymmetrical

Question 7

Describe how to carry out a cover test?

Answer 7

This should be carried out at near (1/3 of a metre) using a light and an accommodative target and at distance (6 metres) to an accommodative target. Some squints may be intermittent and only apparent when focussing is exerted at near. Others may only be present on distance fixation. If the patient wears glasses a cover test should be carried out with and without glasses to see what effect the glasses have on the size of the deviation.

• As you cover one eye, watch the opposite eye for movement –if no movement repeat covering other eye
• If the opposite eye moves to fix on target = tropia (manifest squint)
The direction of movement tells you which type

Question 8

You see outward movement of the eye in cover test….

Answer 8

ESOtropia (convergent squint)

- the eye would have started inwards in primary position

Question 9

Esotropia

Answer 9

You see outward movement of the eye in cover test

The eye would have started inwards in primary position

Question 10

You see inward movement of the eye in cover test….

Answer 10

Exotropia (divergent squint- eyes come together)

The eye would have started outwards in primary position

Question 11

Exotropia

Answer 11

You see inward movement of the eye in cover test….

The eye would have started outwards in primary position and then they DIVERGE

Question 12

You see upward movement of the eye in cover test….

Answer 12

Hypotropia (low eye)

Eye would have started downwards in primary position

Question 13

Hypotropia

Answer 13

You see upward movement of the eye in cover test….

Eye would have started downwards in primary position

Question 14

You see downwards movement of the eye in cover test….

Answer 14

Hypertropia (high eye)

The eye would have started upwards in primary position

Question 15

Hypertropia

Answer 15

You see downwards movement of the eye in cover test….

The eye would have started upwards in primary position

Question 16

If the ocular muscles are normal there should be no ________ left in either eye in each position of gaze

Answer 16

visible sclera

VISIBLE SCLERA = weak muscle

Question 17

1) Test of Lateral Rectus
2) Test of Medial Rectus
3) Test of Superior Rectus
4) Test of Inferior Rectus
5) Test of Inferior Oblique
6) Test of Superior Oblique

Answer 17

1) Abduction of eye
2) Adduction of eye
3) Elevation in Abduction
4) Depression in Abduction
5) Elevation in Adduction
6) Depression in Adduction

Question 18

1) Abduction of eye
2) Adduction of eye
3) Elevation in Abduction
4) Depression in Abduction
5) Elevation in Adduction
6) Depression in Adduction

Answer 18

1) Test of Lateral Rectus
2) Test of Medial Rectus
3) Test of Superior Rectus
4) Test of Inferior Rectus
5) Test of Inferior Oblique
6) Test of Superior Oblique

Question 19

5 things to ask about in history taking?

Answer 19

1. a) reduced vision
2. b) red eyes
3. c) discomfort
4. d) double-vision
   e) disturbance of vision

Question 20

Describe examination of the pupils?

Answer 20

Direct response in each eye (check eye shining)
Repeat to check consensual response (check eye not shining)
Swinging light test (rapid movement to check both stay equally constricted, if one dilates test is postiive and suggests optic nerve or retina problem)

Question 21

Describe exam of visual acuity and the snellen chart?

Answer 21

Should wear glasses if have them, note this down though.
Top number equates to metres and bottom to position of chart e.g. 6/6 you can see at 6m what is expected. The other number says the distance someone would be able to see those letters away. For example if person can only read to 36 line then they can see at 6m what a person with normal vision can see at 36m away. If they get some wrong you do 6/36 -2 or plus whatever if only onto the next line. If doesn’t get 6/6 should do pinhole test, if improves they have an uncorrected refractive error. If can’t read the top line move them to 3m. If still can’t read ask to count fingers, then detect hand motion then detect light.

It is possible in an exam that you will have a mini-Snellen. This will look like a normal Snellen however it will be smaller. When using a mini- Snellen you must ask your patient to stand 3m from the chart and not 6. However acuity will still be recorded as 6/the number of the line readable on the chart, as normal.

Question 22

Snellen Codes

1) Not wearing glasses
2) Wearing Glasses
3) Wears glasses but doesn’t have them
4) Improved with pinhole
5) Able to count fingers
6) Detects hand movement
7) Perceive lights
8) Doesn’t perceive light

Answer 22

UA if unaided
 C Gl for wearing glasses
 S Gl for not wearing glasses, but normally wears them  C CL for wearing contact lenses
 PH for improved sight with pin hole test

Ask them to count fingers (hold your hand in front of them). If patient able, record acuity as CF
o If they cannot count your fingers then wave your hand in-front of patient. If patient detects hand motion, record acuity as HM
o If the patient cannot detect hand motion then shine a light into their eye (in all four quadrants of each eye). If patient can perceive light record acuity as LP
o If the patient has no light perception you can record acuity as NLP

Question 23

Describe visual acuity vs visual fields

Answer 23

Visual Acuity: the ability to discriminate high contrast fine detail at a distance; the sharpness and clarity of vision”
Visual field: Complete range of central and peripheral vision

Question 24

Describe examination of visual fields?

Answer 24

•  The examiner and subject should be seated approximately 70 -100cm apart such that the hand / fingers occupy a plane midway between them.
•  Use simultaneous presentation of hands as screen for hemianopia with both of the patient’s eyes open.
•  Ask the patient to cover one eye, examiner then covers the opposite eye so that the patient is sitting with his left eye covered looking into the examiners uncovered left eye and vice versa. Tell the patient to look into the open eye at all times.
•  Imagine a cross centred on the patient’s pupil and present 1 or 2 fingers in each of the quadrants avoiding the meridian. Repeat with the other eye.
• Test peripheries by bringing in a white pin
Test blind spot by putting orange pin in middle and move from nasal to temporal and identify boundaries of blind spot and compare to own.

Question 25

On image of back of eye how can you tell which eye is which?

Answer 25

Optic disc is on nasal side