Ophthalmic Hx and Examination Flashcards
What is important in the history of eye issue
MUST rule out emergencies Uni or bilateral Time of onset Permanent or transient Relieving factors and precipitants Normal baseline Recovery - full or partial Associated Sx Associated conditions - HTN / DM
What do you want to know about red eye
Change in vision Pain - What is it like - How long for and when does it happen Any other Sx or associated features Discharge Double vision Any floaters / halo Headache
What do you want to know about change in vision
Uni or bilateral Sudden or gradual Recovery Transient - i.e. better after blinking or permanent Type of loss - blurred/ tunnel PAINFUL OR PAINLESS Associated Sx - pain / red / discharge Any amblyopia
What do you want to know about pain
Is it painful or just discomfort / grit
Ocular surface pain (blepharitis, conjunctivitis, keratitis, ulcer, dry eyes)
- Gritty
- FB sensation
- Sharp
Internal ocular (uveitis / scleritis / glaucoma)
- Throbbing
- Dull ache
Pain on movement
- Optic neuritis
- Scleritis
Anything that makes it better - painkiller / eyedrops
Anything that makes it worse - light / movemnt
Associated Sx
What associated Sx
Visual disturbance Diplopia Distortion Photophobia Headache Pain within eye Pain around eye - sinusitis Floaters Trauma to eye Discharge- watery vs pus Dry eyes Blocked nose itch
What do you want to know about discharge
Colour Type Constant or intermittent Acute or chronic Itch
What do you want to know about double vision
Uniocular (present when covering one eye)
Binocular (relieved covering one eye)
What does uniocular suggest
Ocular issue
What do you want to know
Onset
Releiving factor
Distortion which suggests macular cause
What does binocular suggest
Neuro problem e.g. cerebral artery aneurysm
What do you want to know
Vertical or horizontal Sudden or gradual Permanent or transient Precipitants Relieving Associated neuro
What is important in past ophthalmic Hx
Has it happened before Eye surgery - Strabimus - Cataract - Laser Contact lenses use - Last assessment, how long and how cleaned Ambylopia in childhood Any trauma
What is important in PMH
HTN or DM Atopy CVS RF Joints Bowels for IBD Exposure to infections - any sinus infections
What is important in social HX
Recent travel Smoking Alcohol Drugs STI Animals
What do you look for in inspection
Facial asymmetry Rash Lid position Globe abnormality Pupil asymmetry Any lumps / red / discharge
What are types of lid position
Ptosis - dropping
Entropion = inverted so lashes can rub against eye
Ectropian = everted + droopy
What are globe abnormalities
Proptosis = forward Enopthalmos = posterior
What is acute red eye typically affecting
Anterior segment
What does visual loss tend to affect
Posterior segment
What is the best way to examine eye
Front to back
Assess vision
Assess anterior segment
Assess posterior segment
How do you examine
General inspection Visual acuity Colour vision Pupils Slit lamp Fundoscopy - optic nerve Optic nerve Ocular movement
What do you need
Snellen chart
Opthamloscope
Slit lamp
How do you assess visual acuity
Visual acuity with Snellen chart
- Do each eye separate
- Wear glasses
What should you do if vision reduced
Ask to look through pinhole
This will correct refractive error
What is used to assess visual field
Using fingers will only show gross defect
If suspect need to refer for formal testing
Perimetry
Field Analyers will change colour for defects
Used to asses neuro / glaucoma - peripheral
What will macular hole cause
Central loss or distortion
What will retinal detachment cause
Peripheral field defect
What does a monocular defect suggest
Problem in that eye or optic nerve to chiasm
After dicussation any lesion will cause defect in both eyes
Optic nerve disease
Central scrotoma
How does retinal disease present
Causes defect in opposite half of visual field
A large scar in inferior retina will cause a superior field defect
Inferior branch retinal vein occlusion = monocular superior loss
When is colour vision common reduced
Optic nerve centrally
Peripherally with chiasm
What happens in particular
Red desaturation
What is used to test
Colour plates
Use for all suspected optic nerve / neurological disease
When is colour normal
Glaucoma
How do you assess pupils
Ask to fixate on distant target
- Are pupils normal sizes and equal
Reduce light
- Are pupils still equal
Check light response
- Shine light in one eye and check direct resposne
- Check the consensual response
Accommodation
- Ask to fixate on distant object
- Introduce a new object close and ask them to focus
How do you assess eye movement
Is there diplopia in primary position Ask patient to follow a target Ask if they have any double vision Ensure not monocular by getting them to cover one eye and making sure it disappears Describe orientation of diplopia
What commonly causes horizontal diplopia
6th nerve palsy
Decompensated horizontal squint
What commonly causes tilted / vertical
4th nerve palsy
Diplopia + ptosis
3rd nerve palsy
EMERGENCY
If doesn’t fit CN pattern
Supranuclear or localised ocular
What do you look for in slit lamp examination
Anterior segment
- Conjunctiva
- Cornea
- Iris
HYphaema = blood in AC Hypopyan = pus in AC
What do you look for with conjunctiva
Any discharge Does it look bumpy - Allergy - Viral conjunctivitis Any hyperaemia - Episcleritis - superficial - Scleritis - deep - Uveitis - Blepharitis - at lid margins
What do you look with cornea
Clear vs hazy Hazy due to corneal oedema Corneal ulcer = local opacity only Swelling White area in red eye indicates stoma infiltrate in keratitis Add flurosecin
What does fluroscein do
Looks for epithelial defect
- Dendritic ulcer
- Infection / abrasion
If painful post corneal transplant
Senior help
- Could be infection or rejection
What is the anterior chamber
Area between cornea and iris
What do you look at in anterior chamber
Is anterior chamber normal depth or shallow
- If shallow need to exclude an occludable angle with gongioscopy as cause glaucoma
Can you see light in anterior chamber
- No usually appears empty and only see light shone on cornea and iris
- Suggests inflammation or infection
Iris
Is colour the same in both eyes
Is it stuck to lens - synechiae (makes pupil irregular and sign of inflammation)
Any iris transillumination defects
What is tonometry used for
Measure IOP
Too thick fluroscein can underestimate
What is gonioscopy
Examine angle
Better in dark
Cannot exclude an occluded angle without performing
What does posterior segment involve
Dilating pupil - essential to see behind the lens
Lens
Vitreous
Fundoscopy
Before dilating pupil what should you check
No driving as will blur eye
Ensure pupil response checked as won’t be able to for 24 hours
May be only +Ve sign in optic neuritis
What do you use to dilate
Tropicamide - fasted acting
Phenylephrine
Most common cause of gradual vision loss
Cataract
What do you look for in the lens
Lens opacities - sign of cataract
Loose len zonules - blunt trauma
Dislocated lens (not in centre) - causes astigmatism
Artificial lens implant after cataract
What do you look for in vitreous (usually clear)
Dust
White cells - vitritis
Red cells - haemorrhage
What do you do in fundoscopy with opthamolscope
Check red red reflex Look optic disc Assess vessels radiating Look at macula Look in all 4 peripheral quadrants of retina
Important things to note in disc
Swelling
CUpping
Abnormal vessels
Important things to note with macula
Haemorrhage
Oedema
Exudates
Atrophy
Important things to note in retina
Retinal degeneration
Breaks
Haemorrhage
Exudates
What must all examinations have
Assessment of vision
Tonometry as glaucoma asymptomatic
Thereafter tailor to Sx
If loss of vision
Need to dilate pupil as usually due to posterior issue
If suspect acute angle glaucoma
Goniosopy only way to exclude
What is medical emergency
Papilloedema
Enlarged and engorged
What is critical
CN examination
