Eye exam

Question 1

Eye exam

Answer 1

Inspection
- Head size and shape
- 4 Ss: shunt, stigmata, scoliosis, scars
- Head tilt?
- Ptosis?
- Eye, iris and pupil shape, symmetry
- Corneal clouding

1. Pupils
   
   • Symmetry (coloboma)
   • Direct and consensual reflex (pupil should constrict in same eye and opposite eye when light shone in that eye)
   • RAPD (dilation of pupil when should constrict indicates optic nerve pathology)
     * Accommodation (look at cielling then at finger - will tell u if glass eye)
2. Acuity (do this first!)
   
   • Snellen chart if >5yo
   • E chart 3 - 4yo
   • -> with glasses if they wear them. not without
     **If young infant, test fixing/following
     **If can’t read top line then comment on number of fingers/light acuity
3. Inattention and Fields (without glasses)
   - in younger children distract them and then get them to follow red ball from behind
4. H test
5. Nystagmus (cerebellar pathology)
6. Fundoscopy
7. Comment on slit lamp

Question 2

Bitemporal hemianopia ddx

Answer 2

Pituitary tumour/craniopharynoma/suprasellar meningioma at optic chiasm

Question 3

Homonymous hemianopia ddx

Answer 3

Surgery, optic neuroma/tumour, ischaemia to optic nerve BEFORE optic chiasm

Question 4

L or right monocular VF defect ddx

Answer 4

Tumour, ischaemia to optic nerve AFTER optic chiasm

Question 5

Central scotoma (pin disappears temporarily as pin is moved across centre of field of vision)

Answer 5

Optic glioma
MS
Papilloedema
Macular degeneration

Answer 6

• Supra nuclear palsy: B/L loss of vertical (later also horizontal) gaze =MS
  
  • CN3 palsy - ‘down and out’ at rest + ptosis + fixed/dilated pupil
  • CN4 palsy -
  • CN6 palsy -

Question 7

Ddx for EOM gaze palsy

Answer 7

Vascular - ischaemic stroke/haemmhorage
Post viral
Tumour, NF1
Raised ICP

Question 8

‘down and out’ at rest + ptosis + fixed/dilated pupil = ?

Answer 8

= CN3 palsy

Question 9

pupil higher on affected side at rest + head tilt = ?

Answer 9

= CN4 palsy

Question 10

pupil inwards at rest and unable to abduct laterally

Answer 10

= CN6 palsy

Question 11

Failure of accommodation reflex ddx

Answer 11

Optic nerve lesion (afferent)
- Trauma
- Compression (tumour)
- Ischaemia
- Optic neuritis

Midbrain lesion
- infection, tumour, trauma

CN3/ Oculomotor lesion (efferent)
- Trauma
- Compression (tumour)
- Ischaemia

Question 12

Ptosis ddx

Answer 12

Muscle
- NMG: MG, botulism (fatiguability w upward gaze)
- muscle (myotonic dystrophy, THYROID)
- congenital

Nerve (pupils abnormal)
- CN 3 palsy: dilated pupil + failure of abduction/lat gaze
- Horners: constricted pupil

Question 13

ddx Leucocuria

Answer 13

Cataract
Retinoblastoma
Retinal detachment
Retinopathy of prematurity
Intraocular infection (endophthalmitis)