External Exam and Pupils Flashcards
When does the exam start?
before you even begin taking case history. Look at patient’s eyes as soon as you walk in the room
What should you try to observe?
- 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
If something looks funny..
- ask patient about it
- record Hx and observations in EMR
Prior to SLE use naked eye, penlight, or trans-illuminator to examine…
- large lesions
- eyelid postions
- eyelid movements
What eyelid positions would you need to observe?
- palpebral aperture (vertical distance between upper and lower lid)
- ptosis/refraction vs exophthalmos/enophthalmos
palpebral aperture
vertical distance between upper and lower lid
What eyelid movements should you obeserve?
- checking forced closure bilaterally
- checking upper lid movement with up gaze may be diagnostic
What if you find something abnormal?
- ask pt without implying abnormality (previous trauma, surgery..onset/duration)
- old photos helpful
- additional testing
Pupil - optics
aperture
pupil - physiological
tissue
Pupil
not a structure you can touch. opening in iris
What is the importance of pupil evaluation
- neurological
- ocular
- systemic
What is considered one of the ophthalmic sign?
Pupils
vision/pupil/pressures
how do we evaluate pupils?
- shape/position/color (iris)
- size
- light reflexes
- “swinging flashlight” test
- near response
Pupil: shape, position, color (iris)
- normal vs ab (round, near-centered)
- position (off to side, abnormal)
- heterochromia, transillumination, atrophy, etc
corectopia
eccentricity of pupil
usually not centered or shaped correctly
heterochromia iridis
2 different colors of iris
What increases pupil size?
sympathetic activation of radial dilator muscle
what decreases pupil size
parasympathetic activation of sphincter muscle
dilation
enlargement of pupil via sympathetic activation (homatropine) or parasympathetic block (tropicamide)
homatropine
sympathetic activation
tropicamide
parasympathetic block
What conditions are pupil size measured?
normal light (photopic) and dark (scotopic) conditions
hippus
normal fluctuation. fluctuates constantly
pupil size: age 20
5mm (light)
8mm (dark)
pupil size: age 80
2mm (light)
2.5mm (dark)
what happens to pupil size with age?
decreases. Lose sympathetic tone
abnormal findings of the pupils…
- bilateral/unilateral
- apparent at all light levels or greater in dark or light
anisocoria
a significant difference in size between pupils
What is considered to be a significant difference in pupil size?
1mm or more
How do you measure size of someone’s pupils with anisocoria?
in the dimmest possible light and brightest possible light. allows you to determine which pupil is abnormal
physiologic anisocoria
fairly common, non pathological, but a Dx of exclusion requiring you to rule out any pathology
afferent
sensory nerve fibers leave each eye via optic nerve and about half cross to opposite side at optic chiasm
efferent
motor fibers leave the brain from EW uncle on each side of the brain, each of which sends signals to both eyes
light received in one eye…
should cause constriction in both pupils
swinging flashlight test
- 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
What will cause a weaker direct response than consensual response in pupil?
- an eye with a relative afferent pupillary defect (RAPD or MG)
- can be recorded subjectively or objectivley
pupillary near reflex
- accommodation
- convergence
- pupillary miosis
PERRL
Pupils Equal Roud Reactive to Light with no APD
APD
afferent pupillary defect
