Ocular Diagnostics Flashcards
Eye Vitals
*Visual Acuity
*Pupillary Exam
Visual Fields
Ocular Motility
*Tonometry
Exam
Visual Acuity Tools
Distance: Snellen
Near: Rosenbaum card
Tumbling E
3-7 yr olds: HOTV
Good for kids/illiteracy: Allen picture chart
Preverbal/nonverbal: Fixes & follows, central/steady/maintains
Snellen Chart
Recorded as ratio
Numerator is distance from chart (feet or m)
Denominator is distance at which letters can be read by person w/ unimpaired vision
(e.g. 20/70 means you can see at 20 feet what “normal” vision sees at 70 feet)
Rosenbaum chart
Held 14 inches from face
Recorded as ratio or Jaeger number.
Ratio is easier for patients to understand, you to explain and widely used by ophthalmologists
VA
visual acuity
CC
w/ glasses (correction)
SC
without glasses (w/o correction)
OD
right eye (oculus dexter)
OS
left eye (oculus sinister)
OU
both eyes (oculus uterque
Which eye is conventionally recorded first?
RIGHT (OD)
What to do if patient can’t see largest letter on eye chart…
- REDUCE DISTANCE to chart
- No letters @ <3ft? –> COUNT FINGERS (CF)
- No fingers? HAND MOTION (HM)
- No movement? PRESENCE of LIGHT (LP)
- No light? NO LIGHT PERCEPTION (NLP)
Pinhole occluder
Pinholes correct for refractive error (dry eyes, cataracts)
PERRLA
Pupils equal, round, reactive to light
Direct? Consensual?
Relative afferent pupillary defect
Swinging flashlight test
Abnormal response: Dilation rather than constriction
Indicates lesion of nerve on affected side
Eyes follow 6 cardinal directions
Right, up Right Right, down Left, up Left Left, down
Right, up muscles
Right superior rectus
Left inferior oblique
Right muscles
Right lateral rectus
Left medial rectus
Right, down muscles
Right inferior rectus
L superior oblique
Left, up muscles
Left superior rectus
Right inferior oblique
Left muscles
Left lower rectus
Right middle rectus
Left, down muscles
Left inferior oblique
Right superior oblique
Strabismus
Misaligned Eyes
One eye w/ limited movement, Both eyes limited movement together, Nystagmus
Nystagmus
Dancing eyes (oxoclonus/myoclonus –> strong correlation w/ neuroblastoma)
Esotropia
Eye deviated medially
Exotropia
Eye deviated laterally
Hypertropia
Eye deviated superiorally
Hypotropia
Eye deviated inferiorally
Confrontation visual fields
Tests peripheral vision for gross defects only
Tonometry
Measures intraocular pressure
Helpful for glaucoma screening
Start w/ drop of proparacaine/tetracaine
TIPS: tell patient to breathe normally & don’t push on globe
Normal IOP
10-21 mm Hg
External Eye Inspection
Inspect eyelids and eyelashes (bruising, swelling, mattering)
Tearing
Rashes or skin lesions
Inspect conjunctiva/sclera (penlight or muscle light)
Palpate orbit
Palpate lymph nodes
Slit lamp exam
Binocular microscope
3D view of eye
Most useful to look at anterior eye (Corneal abrasions, foreign bodies, trauma)
Can use fluorescein
Fluorescein staining
Looks at defect in corneal epithelium
Use anesthetic drop first
Remove contacts first!! (Can stain)
Eyelid inversion
Suspected foreign bodies
Vertical defect w/ fluorescein staining
Have patient look down, pull lid inferiorly/anteriorly and rotate superiorly over CTA
Ophthalmoscope Evaluates For
Red reflex Optic disc Retinal circulation Retinal background Macula (if you're impressive)
Cotton wool spots
Signs of ischemia or infarct in retina
Blood & Thunder
Vein occlusion & edema in eye
Typically due to HTN
Amsler Grid
Evaluates visual distortion w/ grid (for macular degeneration or other visual distortion)
Visual field defects
Central field defects
Metamorphopsia
Visual Distortion
Scotoma
Blind spot
CT for eyes
Always in traumas
Infection? Do CT w/ contrast
MRI for eyes
w/ and w/o contrast
good for neural structures
Make sure to do “fat suppression”
IIH? MRI w/ MRV to look @ venous system
Fluorescein angiography for eye
Evaluate retinal bloodflow (leakage)
Central serous retinopathy, macular degeneration
Ultrasonography for eye
Large black circle is vitreous humor
See detached retina (line through vitreous humor)
OCT
Optical coherence tomography
Infrared light penetrates retina
Can see downt o 10-15 microns
Can distinguish 15 layers of retina
When to refer pt. w/ reduced visual acuity?
Worse than 20/20 (or documented baseline) w/ visual symptoms in one or both eyes
Worse than 20/40 in both eyes w/out symptoms
Assymetry (difference of 2+ lines on Snellen chart)
Pesbyopia (reduced near vision w/ no change in distance)
When to refer abnormal fundus appearance?
Wide range of normal
Use discretion & resources
Don’t be afraid to reach out to ophtho
When to refer elevated IOP?
> 22mm Hg
