External Exam and Pupils

Question 1

When does the exam start?

Answer 1

before you even begin taking case history. Look at patient’s eyes as soon as you walk in the room

Question 2

What should you try to observe?

Answer 2

• gate and mobility as they enter the room
• observe their speech and apparent mental status
• does anything look unusual?
• head and face (symmetry/tilt)
• ocular adnexa and eyes

Question 3

If something looks funny..

Answer 3

• ask patient about it

- record Hx and observations in EMR

Question 4

Prior to SLE use naked eye, penlight, or trans-illuminator to examine…

Answer 4

• large lesions
• eyelid postions
• eyelid movements

Question 5

What eyelid positions would you need to observe?

Answer 5

• palpebral aperture (vertical distance between upper and lower lid)
• ptosis/refraction vs exophthalmos/enophthalmos

Question 6

palpebral aperture

Answer 6

vertical distance between upper and lower lid

Question 7

What eyelid movements should you obeserve?

Answer 7

• checking forced closure bilaterally

- checking upper lid movement with up gaze may be diagnostic

Question 8

What if you find something abnormal?

Answer 8

• ask pt without implying abnormality (previous trauma, surgery..onset/duration)
• old photos helpful
• additional testing

Question 9

Pupil - optics

Answer 9

aperture

Question 10

pupil - physiological

Answer 10

tissue

Question 11

Pupil

Answer 11

not a structure you can touch. opening in iris

Question 12

What is the importance of pupil evaluation

Answer 12

• neurological
• ocular
• systemic

Question 13

What is considered one of the ophthalmic sign?

Answer 13

Pupils

vision/pupil/pressures

Question 14

how do we evaluate pupils?

Answer 14

• shape/position/color (iris)
• size
• light reflexes
• “swinging flashlight” test
• near response

Question 15

Pupil: shape, position, color (iris)

Answer 15

• normal vs ab (round, near-centered)
• position (off to side, abnormal)
• heterochromia, transillumination, atrophy, etc

Question 16

corectopia

Answer 16

eccentricity of pupil

usually not centered or shaped correctly

Question 17

heterochromia iridis

Answer 17

2 different colors of iris

Question 18

What increases pupil size?

Answer 18

sympathetic activation of radial dilator muscle

Question 19

what decreases pupil size

Answer 19

parasympathetic activation of sphincter muscle

Question 20

dilation

Answer 20

enlargement of pupil via sympathetic activation (homatropine) or parasympathetic block (tropicamide)

Question 21

homatropine

Answer 21

sympathetic activation

Question 22

tropicamide

Answer 22

parasympathetic block

Question 23

What conditions are pupil size measured?

Answer 23

normal light (photopic) and dark (scotopic) conditions

Question 24

hippus

Answer 24

normal fluctuation. fluctuates constantly

Question 25

pupil size: age 20

Answer 25

5mm (light) | 8mm (dark)

Question 26

pupil size: age 80

Answer 26

2mm (light) | 2.5mm (dark)

Question 27

what happens to pupil size with age?

Answer 27

decreases. Lose sympathetic tone

Question 28

abnormal findings of the pupils...

Answer 28

- bilateral/unilateral | - apparent at all light levels or greater in dark or light

Question 29

anisocoria

Answer 29

a significant difference in size between pupils

Question 30

What is considered to be a significant difference in pupil size?

Answer 30

1mm or more

Question 31

How do you measure size of someone's pupils with anisocoria?

Answer 31

in the dimmest possible light and brightest possible light. allows you to determine which pupil is abnormal

Question 32

physiologic anisocoria

Answer 32

fairly common, non pathological, but a Dx of exclusion requiring you to rule out any pathology

Question 33

afferent

Answer 33

sensory nerve fibers leave each eye via optic nerve and about half cross to opposite side at optic chiasm

Question 34

efferent

Answer 34

motor fibers leave the brain from EW uncle on each side of the brain, each of which sends signals to both eyes

Question 35

light received in one eye...

Answer 35

should cause constriction in both pupils

Question 36

swinging flashlight test

Answer 36

- afferent pupillary defects - pupils usually of equal size; unlike with efferent defects which cause anisocoria - compares the direct and consensual light responses of the same eye

Question 37

What will cause a weaker direct response than consensual response in pupil?

Answer 37

- an eye with a relative afferent pupillary defect (RAPD or MG) - can be recorded subjectively or objectivley

Question 38

pupillary near reflex

Answer 38

- accommodation - convergence - pupillary miosis

Question 39

PERRL

Answer 39

``` Pupils Equal Roud Reactive to Light with no APD ```

Question 40

APD

Answer 40

afferent pupillary defect