Ophthalmology: History & Examination

Question 1

Briefly outline how you would examine the eyes & vision if asked to in an OSCE

Answer 1

• Introduction
• General inspection
  
  • Surroundings
  • Patient
• Visual acuity (Snellen, LogMAR or if can’t see those count fingers etc..)
• Near vision
• Colour vision (Ishihara plates)
• Visual fields
• Blind spot
• Closer inspection of eye (surroundings, lids, pupils)
• Light reflexes:
  
  • Direct
  • Consensual
  • Swinging light test
• Accommodation reflex
• Strabismus if appropriate
  
  • Corneal reflex test (Hirschberg test)
  • Cover test
• Eye movements/extra-ocular muscles (move in H shape)
• Fundoscopy
  
  • Fundal reflex
  • Optic disc
  • Macula
  • Other parts of retina for pathology
• Complete examination (depends on what found)
  
  • ?Amsler chart
  • ?Cranial nerve examination
  • ?BP
  • ?Glucose/HbA1c
  • ?Retinal photography/OCT

See geeky medics for full: Examination of the Eyes and Vision - OSCE Guide | Geeky Medics

Question 2

For each of the following signs on fundoscopy, state what they indicate:

• Dot & blot haemorrhages
• Flame haemorrhages
• Cotton wool spots
• Hard exudates

Answer 2

• Dot & blot haemorrhages: deeper in retina (diabetic retinopathy)
• Flame haemorrhages: in superficial ganglion nerve fibre layer (hypertension & venous stasis)
• Cotton wool spots: areas of retinal infarction
• Hard exudates: lipid deposits

Question 3

How do you distinguish between hard exudates & cotton wools spots?

Answer 3

• Cotton wool spots: fluffy
• Hard exudates: not fluffy/clearly defined border

Question 4

Discuss how you can tell/narrow down where pathology is if there is absence of red reflex

Answer 4

• If can see iris, then cornea must be okay
• Hence, pathology must be in lens or vitreous

Question 5

Descriptions of fundoscopy with individual condition FC- make sure can recognise. See geeky medics for more.

Question 6

Summary from UHL guidelines for referral of ophthalmological conditions

Answer 6

Microsoft Word - LRI ED eye refs-3.doc (leicestershospitals.nhs.uk)

Question 7

What fundoscopic changes might you see in pts with raised ICP?

Answer 7

• Blurring of the optic disc margin
• Elevated optic disc (look for the way the retinal vessels flow across the disc to see the elevation)
• Loss of venous pulsation
• Engorged retinal veins
• Haemorrhages around optic disc
• Paton’s lines which are creases in the retina around the optic disc

TOM TIP: It can be tricky to learn to recognise papilloedema. When looking for elevation of the optic disc, look at the way the retinal vessels flow across the disc. Vessels are able to flow straight across a flat surface, whereas they will curve over a raised disc.