Eye Exam Flashcards
The following equipment is required for a thorough functional and structural examination of the eye:
- Snellen Eye Chart
- Near Vision Eye Card
- Bright Penlight or Transilluminator
- Direct Ophthalmoscope
- Sterile Fluorescein Strips
- Sterile Irrigating Solution
Examination of the ocular fundus with the direct ophthalmoscope allows you to visualize two tissues in their living state that may not be observed directly in any other part of the body:
the optic nerve and the retinal vasculature. Changes in the optic nerve may mirror changes occurring in other areas of the central nervous system, and abnormalities of the retinal vasculature may suggest similar pathologic changes in other vessels.
T or F.
T. The visual acuity of a patient with an ocular complaint must be recorded before consulting with an ophthalmologist. This information is vital to the ophthalmologist in judging the relative emergent nature of the problem. Failure to measure the visual acuity on any but an unconscious or uncooperative patient is not considered good medical practice.
Ocular complaints can be grouped into six large categories:
(1) visual complaints,
(2) pain in and around the eye,
(3) a red eye,
(4) flashes and floaters,
(5) diplopia, or
(6) trauma to the eye and/or orbit.
Complaints of loss of vision should be categorized as acute or gradual in onset, rapid or slow in progression, unilateral or bilateral in involvement, and painless or painful in nature. You should question the patient about associated symptoms such as weakness in the extremities, diplopia, dizziness, headache, or numbness. You should also inquire about previous corrective lens wear, trauma to the eye, amblyopia (lazy eye), or other causes of decreased vision. Many times the cause of decreased visual acuity is already known to the patient.
Pain around the eye may be of ocular origin or be referred from pathology in the orbit, surrounding sinuses, or cranial cavity. Common examples of referred pain around the eye are:
sinus disease, orbital tumors, and post-herpetic (zoster) neuralgia. You should examine the orbit carefully, looking for subtle or obvious proptosis of the globe or fullness of the lids and palpating for abnormal masses.
Pain in the lid is often associated with acute inflammatory diseases such as:
a hordeolum (stye).
Most pain related to the eyeball can be characterized as one of two types:
(1) foreign body sensation or (2) dull, aching, boring pain.
Foreign body sensation usually indicates a corneal or conjunctival foreign body or a corneal abrasion. Occasionally patients with conjunctivitis or dry eye syndrome may complain of lesser degrees of scratchiness. Aching pain of ocular origin is usually caused by either inflammation within the eye (iritis, infection) or a rapid rise in intraocular pressure (angle closure glaucoma).
Photophobia (painful sensitivity to light) may be caused by what things?
iritis (anterior uveitis),
corneal abrasion, corneal foreign body, corneal ulcer, or other corneal surface disease.
Occasionally, meningeal irritation may cause photophobia.
A _________ is one of the most common eye complaints encountered by both the ophthalmologist and non-ophthalmologist.
red eye
Differential diagnosis of a red eye
When are flashers and floaters common?
Flashes and floaters are usually seen in older patients and may vary in severity. Most older patients and younger individuals with myopia (near-sightedness) have floaters that do not indicate a serious medical condition of the eye, but this symptom always warrants a careful examination.
An abrupt onset of new floaters or an increase in the number, size, or character of floaters is a cause for concern.
The association of floaters with light flashes, especially on turning the head quickly, should alert you to the possibility of a more serious problem such as:
retinal detachment.
Other symptoms that are even more ominous are those of a portion of the visual field being blocked off or a curtain came down in front of my eye. Patients with new flashes and floaters should have a dilated fundus examination by an ophthalmologist using an indirect ophthalmoscope. Most of these examinations do not reveal a retinal detachment, but, nevertheless, a careful evaluation is required. A follow up examination is performed after 4 to 6 months.
How should a complaint of double vision be handled?
You should refer most patients with double vision for consultative opinion. However, proper evaluation of this important symptom is essential to arrive at the correct diagnosis and referral to the appropriate specialist.
The patient should be questioned about the circumstances that bring on diplopia; the gaze direction that seems to separate the two images to a greater or lesser degree; and any associated neurological symptoms such as headache, dizziness, vertigo, weakness, numbness, or changes in sensorium. A history of diabetes mellitus is always sought in any patient with diplopia, because palsies of cranial nerves III, IV, and VI are commonly seen in this disease
Suspected trauma to the eye
If this history is discovered, you must obtain an X-ray (PA or Water’s view and lateral views) to rule out the presence of an unsuspected radio-opaque intraocular foreign body. You must NOT rely on the absence of major abnormalities in the ocular examination to rule out the presence of foreign material hidden within the globe. Nonradioopaque foreign materials such as wood may not be seen on any imaging studies. Their presence should be suspected on the basis of the history of the injury.
Careful examination of the orbit and globe is required if trauma to the orbit or lids has occurred. Even after seemingly trivial trauma to this region, you should assume that the eye has been lacerated or ruptured or that the patient has blood in the anterior chamber of the eye (hyphema) until these findings have been ruled out. You must not place any external pressure on the lid or globe until the intact status of the sclera and cornea is verified. Always gently pull the lids straight up or down, using the orbital rims to support your fingers, rather than pressing backwards against the eyeball. The discovery of an eye with a corneal or scleral laceration or rupture or with blood in the anterior chamber requires an emergent consultation with an ophthalmologist.
Blunt trauma should also suggest the possibility of facial bone fractures. Palpation of the orbital rim to locate areas of tenderness and/or step-off and examination of the extraocular movements, especially up gaze and down gaze, to observe loss of motion of the eye are essential parts of the evaluation of any traumatized eye or orbit. The presence of crepitus (subcutaneous air) in the lids confirms the presence of a fracture into one of the sinus cavities. Appropriate imaging studies should be ordered as required.
The family history is important in determining if there is a predilection for a familial disease in the patient being examined. The four ophthalmic diseases that may have a hereditary component that we are most concerned with are:
(1) glaucoma,
(2) cataracts,
(3) strabismus, and
(4) blindness
that affects multiple members of the family. Retinoblastoma is a malignant intraocular tumor of childhood that may have a strong familial pattern.
A family history of glaucoma is a well-known risk factor for developing open angle glaucoma. You should carefully query the patient concerning glaucoma in the family. However, you must be careful, as many patients will confuse glaucoma with cataracts. Another confounding factor is the treatment by some ophthalmologists of slightly increased intraocular pressure, thus giving the patient a false family history.
My criteria for accepting the diagnosis of open angle glaucoma are:
(1) the relative was told that they had glaucoma, and (2) they used eye drops at least at some stage of disease treatment.
A family history of cataracts is common when many members of the family live to advanced age. This fact probably does not infer a tendency to cataract formation but a family characteristic to achieve these ages. A familial tendency for cataract formation may be suggested if there are several family members with formation of cataracts in youth or in middle age.
Strabismus is the misalignment of the visual axes. There are three types:
paralytic, nonparalytic, and restrictive. Paralytic and restrictive strabismus are usually acquired.
Paralytic strabismus is characterized by what?
paresis of a cranial nerve or nerves resulting in deviation of the visual axes that varies in amount in different gaze directions and limitation of motion of the eye in the field of action of the affected paretic muscle(s).
The patient experiences diplopia (assuming good vision in each eye), and amblyopia does not occur.
Nonparalytic strabismus is characterized by what?
nonalignment of the visual axes that remains fairly constant in all fields of gaze without visible limitation of motion of individual muscles. Diplopia is not a feature of nonparalytic strabismus, and amblyopia may result from the brain’s adaptation to the misalignment of the visual axes.
This latter type is typical of childhood strabismus and may affect many family members. Limitation of motion of the eye may also result from mechanical restriction as seen in Graves’ disease or blow-out fractures of the orbit.
Many systemic medications have ocular side effects. Name some.
Long-term systemic steroid therapy is a common cause of cataract formation. Asymptomatic increases in intraocular pressure may also occur, although this finding is usually associated with prolonged topical steroid treatment.
Ethambutol, hydroxychloroquine, and interferon are but a few of the systemic medications that may be responsible for major ocular complications.
Other things to get during an eye exam Hx:
- Medication list
- Nutritional Hx
- Sexual Hx
- ROS
For patients who are unable to read, for children, and for non-English-speaking patients, you should use charts with numbers, tumbling E, or symbols. Note in the medical record the use of these charts.
If the patient is unable to read the largest letter at the top of the chart at a distance of 20 feet, move the patient closer to the chart and estimate or measure the distance to the chart. This distance now becomes the numerator of the visual acuity fraction, and the size of the largest letter becomes the denominator. Thus, if the patient reads the large 20/200 at 8 feet from the chart, the visual acuity is recorded as 8/200.
If the patient is unable to read the largest letter at any distance, determine if the patient can count fingers held in front of the eye. Hold up one or two fingers and slowly bring them closer to the patient. When the patient can count the fingers accurately, the distance of the fingers from the eye is measured or estimated. The visual acuity is recorded as Counts Fingers (CF) at (@) the distance obtained above.
If the patient cannot count fingers at any distance from the eye, determine if the patient can see your hand moving about 1 foot in front of the eye. If the patient is able to tell you accurately that your hand is moving, the visual acuity is recorded as Hand Motion (HM).
If the patient is unable to detect the motion of your hand, test for the presence or absence of the perception of light. The eye that is not being tested is covered completely and tightly to exclude a response from this eye. A bright light is directed into the eye being examined, and the patient is asked to tell you whether the light is on or off. If the patient can consistently tell when the light goes on and off, the visual acuity is recorded as Light Perception (LP) or Light Perception Only (LPO). If the patient perceives no light, the visual acuity is recorded as No Light Perception (NLP).
Another chart that the examiner may see in common use in the future is the ETDRS (Early Treatment of Diabetic Retinopathy Study) chart. It has five letters on each line and is viewed usually from 4 meters. Look for testing distance information on the specific chart in use. The visual acuity recorded is recorded as the the line on which the patient reads at least three or more of the letters correctly.
In the hospital setting, measuring near visual acuity is often necessary because the patient is unable to ambulate or sit up to use the distant visual acuity charts. A standard near visual acuity card is used and held at the proper distance from the eye. The testing distance is usually printed on the test card (typically, BUT NOT ALWAYS, 14 inches). Failure to use the appropriate distance will result in erroneous visual acuity results.
The Maxwell chart is designed to be used at a distance of ____ from the patient (the foot of the bed).
6 feet
Near-sighted patients, those who wear reading glasses, or patients requiring bifocals should be tested with their glasses if they are available.
Visual acuity is recorded as the smallest line of numbers (usually on near cards) that the patient can read. It must be noted in the medical record that this was a near visual acuity measurement. If not specified as measured at near, the recorded visual acuity will be erroneously assumed to be a distant measurement.
Using a simple pinhole will also help you distinguish reduced visual acuity from uncorrected refractive errors from organic causes of visual loss. How?
The pinhole excludes all those rays except those passing through the pinhole and the center of the lens. These rays strike the lens perpendicularly and are not bent by the lens. This eliminates the refractive error as the cause of decreased vision. Patients with large refractive errors may not correct the visual acuity all the way to 20/20, but it should improve the vision considerably.
Pinhole devices may be purchased or constructed from stiff paper by making multiple holes with a18G needle or large paper clip. Cover one eye and place the pinhole in front of the eye to be tested (see photograph below).
Instruct the patient to move the pinhole around slowly until the clearest view of the letters is obtained. Record the smallest line read by the patient, noting in the medical record that this is the pinhole (PH) acuity.
If visual acuity is corrected to normal with the pinhole, the most likely reason for the reduction in visual acuity is a refractive error. Failure to improve visual acuity with the pinhole would lead you to think of an organic disease process as the cause of the visual loss. Patients with tremors may have difficulty performing this test successfully.
Examination of the orbit involves inspection, palpation, and auscultation. Adequate lighting is essential. The face should be inspected from the front and side of the patient, as well as viewed from above, looking down over the brow.
Judging the forward position of the patient’s lids relative to the front of the superior orbital rims while viewing from the top of the head is a simple way to determine the presence of proptosis, exophthalmos, or enophthalmos without specialized instrumentation.
As with any comparison, determining which side is normal is paramount. Proptosis occurs when the eye is pushed forward by a mass or inflammation.
The skin surfaces of the eyelids and the eyelashes are examined carefully. Having the patient look down or close the eyes gently will facilitate viewing the entire upper lid. Gentle traction with one finger to open up any wrinkles in the skin may be required for a thorough examination. The lower eyelid is usually easily inspected without much difficulty. You should note any masses, areas of erythema, swelling, tenderness, or other abnormalities present on the eyelids and record a detailed description in the medical record.
The conjunctiva and sclera are examined with a penlight. The lower lid is pulled down gently. The patient is asked to look up to examine the lower palpebral conjunctiva (lining the posterior surface of the lids), the inferior cul-de-sac or fornix, and the inferior bulbar conjunctiva (covering the eyeball itself).
The patient is instructed to look down and the upper lid elevated gently so that the superior bulbar conjunctiva may be observed. You should look for increased injection or pallor of the conjunctiva. Recognizing normal variations in the prominence of conjunctival vessels will come from examining many normal patients
While viewing the conjunctiva, you are also examining the underlying sclera. If the eye has been subjected to blunt or incisive trauma, the presence of a scleral laceration or rupture must be ruled out by careful inspection. Inflammation of the sclera or episcleral tissue usually results in a darker, more purplish injection of the vessels and is commonly associated with tenderness of the inflamed area.
Examination of the upper palpebral conjunctival surface requires eversion of the lid. This examination should be done when the presence of foreign material is suspected in this location. Suspicion that a foreign object is on the upper palpebral conjunctiva comes from observing one of the following:
(1) complaint of foreign body sensation but no foreign body or abrasion is detected on the cornea;
(2) observing staining of the upper cornea, especially straddling the upper limbus; or
(3) vertical lines of staining on the cornea.
You may compare the reflection of the light from the bulbar conjunctival surface with that from the corneal surface to visualize the differences in the character of these two reflections.
Staining the tear film with fluorescein may help evaluate the conjunctival and corneal surfaces.
Fluorescein is usually applied from a sterile strip moistened with a drop or two of sterile irrigating solution. If using the larger strips, peel back the outer wrapper and tear off the strip so that about 1 inch of the stained area of the strip remains adjacent to the unstained handle. This amount of fluorescein should be sufficient for any examination.
The patient is instructed to look upward and the moistened strip gently touched to the lower lid margin. The patient is asked to blink several times to spread the dye. A Wood’s lamp or other blue filter is used to illuminate the ocular surface. Areas where the epithelium is disrupted will take up the dye and stain a bright yellow-green when viewed with a Wood’s lamp or cobalt blue filter. It is not necessary to wash the remaining fluorescein from the eye.
Do not use fluorescein if the patient is wearing soft contact lenses, as this action will cause permanent staining of the lenses. Remove the lenses and instruct the patient not to reinsert the contacts for at least 4 hours. Patients with obvious corneal or scleral lacerations do not require the instillation of fluorescein to adequately evaluate their injuries.
Blood in the anterior chamber of the eye (hyphema) is an important finding that should be actively sought in any traumatized eye. This diagnosis requires an immediate consultation with an ophthalmologist
The accumulation of inflammatory cells, either lymphocytes or polymorphonuclear leukocytes, is a sign of severe ocular inflammation or infection. When these cells layer out in the inferior portion of the anterior chamber, it is know as a what?
hypopyon. The presence of a hypopyon should prompt you to consult an ophthalmologist immediately. Some patients with retinoblastoma may present with an accumulation of tumor cells in the inferior portion of the anterior chamber. This accumulation is known as a pseudohypopyon and should alert you to the possible presence of a life-threatening tumor hidden within the eye.
How is the depth of the anterior chamber estimated?
by holding a penlight temporal to the eye and parallel to the iris plane, observing the degree of shadow formation on the iris between the nasal pupillary border and the nasal limbus. A completely illuminated nasal iris with perhaps a small rim of shadow just inside the nasal limbus denotes a deep chamber.
A wide shadow on the nasal portion of the iris as seen in the photograph below indicates a shallow chamber.
It is important to evaluate the anterior chamber depth in all patients but especially before you dilate the pupils, when there has been trauma to the eye or where pain, ocular injection, cloudy cornea, or fixed mid-dilated pupil suggest angle closure glaucoma.
