Opthalmoscopic Exam Flashcards
Week6
1
Q
What are the three concentric coats of the internal eye?
A
- Outer Fibrous Sclera 2. Middle Mascular Choroid 3. Inner Nervous Retina.
2
Q
What part of the internal eye is visualized with an opthalmoscope?
A
Sclera anteriorly and the retina.
3
Q
What structure has a transparent vitreous body?
A
Inside retina.
4
Q
Retina
A
Visual receptive layer of eye where light waves changed into nerve impulses.
5
Q
What are the structures of the retina viewed with the opthalmascope
A
Optic disk, retinal vessels, general background and macula.
6
Q
Optic Disc
A
area in which fibers from retina converge to form the optic nerve.
7
Q
Where is the optic disc located?
A
Toward the nasal side of the retina.
8
Q
What are the characteristics of the optic disc?
A
- color creamy yellow-orange to pink. 2. Round or oval shape. 3. Margins that are distinct and sharply demarcated, especially on the temporal side. 4. Physiologic cup, the smaller circular area inside disc where blood vessels exit and enter.
9
Q
Retinal Vessels
A
Include a paired artery and vein extending to each quadrant.
10
Q
Where is the macula located?
A
- located on temporal side of the fundus.
11
Q
What are the characteristics of the Macula?
A
Slightly darker pigmented region sourrounding fovea centralis, area of sharpest and keenest vision. Receives and tranduces light from center of visual field.
12
Q
What type of vision is intact in a newborn infant?
A
Peripheral vision.
13
Q
What is the area of keenest vision? when does it develop?
A
Macula. Is absent at birth but mature by 8 months.
14
Q
What type of vision does a 3-4 month old have?
A
Infants establish binocularity and can fixate on a single image with both eyes simultaneously.
15
Q
What shape is the lens at birth?
A
Spherical, growing flatter throughout life.
16
Q
What changes in the lens from birth to old age?
A
Consistency changes from soft plastic at birth to rigid glass in old age.
17
Q
Aging Adult Structure and function changes
A
Pupil size decreases. Lens loses elasticity, becoming hard and glasslike which decreases ability to change shape to accommodate for near vision -> condition is termed presbyopia. By age 70, normally transparent fibers of lens begin to thicken and yellow, the beginning of cataracts. Visual acuity may diminish gradually after age 50, and more so after age 70.
18
Q
Most common causes of decreased visual functioning in older adults are:
A
Cataract formation, or lens opacity, resulting from a clumping of proteins in lens. Glaucoma, or increased intraocular pressure -> chronic open-angle glaucoma is most common type. Macular degeneration, or breakdown of cells in macula of retina. Loss of central vision is most common cause of blindness -> person is unable to read fine print, sew, or do fine work causing great distress.
19
Q
Subjective Data includes
A
-Vision Difficulty (decreased acuity, blurring, blind spots) -Pain -Strabismus, Diplopia -Redness, Swelling- -Watering, Discharge -History of Ocular Problems -Glaucoma -Use of Glasses or Contact Lenses -Self-Care Behaviors
20
Q
What are spots that move in front of your eyes?
A
Floaters are common with myopia or after middle age as a result of condensed vitreous fibers. Usually not significant, but acute onset of floaters (“shade” or “cobwebs”) may occur with retinal detachment.
21
Q
Acute onset of floaters indicates what?
A
Retinal detachment.
22
Q
What is rationale for halos/rainbows around objects?
A
Halos around lights occur with acute narrow-angle glaucoma.
23
Q
What is rationale for blind spots that move as you shift your gaze?
A
Scotoma. a blind spot in the visual field surrounded by an area of normal or decreased vision, occurs with glaucoma, with optic nerve and visual pathway disorders.
24
Q
Rationale for night blindness?
A
Night blindness occurs with optic atrophy, glaucoma, or vitamin A deficiency.
25
Rationale for eye pain?
Sudden onset of eye symptoms (pain, floaters, blind spot, loss of peripheral vision) may be an emergency. Refer immediately.
-Quality is valuable diagnostic indicator. Note that some common eye diseases cause no pain (e.g., refractive errors, cataract, glaucoma).
26
Rationale for crosses eyes?
Strabismus is a deviation in the anteroposterior axis of the eye. is worse when tired.
27
What is Diplopia
the perception of two images of a single object. DOUBLE VISION.
28
Rationale for watering or excessive tearing
Lacrimation (tearing) and epiphora (excessive tearing) are due to irritants or obstruction in drainage of tears.
29
Characteristic of glaucoma
Increased intraocular pressure.
30
What affect does vaginal infections have on a newborn?
Genital herpes and gonorrhea vaginitis have ocular sequelae for the newborn.
31
What activities are taken away with a loss in central vision acuity?
Usual activities such as reading or sewing. usually from macular degeneration.
32
What are the anterior structures of the eye?
Cornea, Anterior and posterior chambers (aqueous fluid), lens
33
What are the posterior sturctures of the eye?
Optic disc, retinal vessels, general background and macula
34
Examination of Optic Disc
-Color: creamy yellow-orange to pink. -Shape: round or oval. -Margins: distinct and sharply demarcated, although nasal edge may be slightly fuzzy. -Cup-Disc Ratio: distinctness varies; when visible, physiologic cup is brighter yellow-white than rest of disc; horizontal diameter is usually less than half the horizontal diameter of the disc.
35
Examination of Retinal Vessels
Follow a paired artery and vein out to periphery in four quadrants noting these points: -Number: paired artery and vein pass to each quadrant; vessels look straighter at nasal side. -Color: arteries brighter red than veins; also have arterial light reflex, with thin stripe of light down middle. -A:V Ratio: ratio comparing artery-to-vein width is 2:3 or 4:5. -Caliber: arteries and veins show a regular decrease in caliber as they extend to periphery.
36
What are he differences in Retinal arteries and veins?
Arteries are light red, are smaller in size, and have a bright light reflex. Veins are dark red, are larger in size and are inconspicuous or absent with light reflex
37
A-V (arteriovenous crossing):
artery and vein may cross paths; not significant if within 2 DD of disc and if no sign of interruption in blood flow is seen; should be no indenting or displacing of vessel.
38
Tortuosity
mild vessel twisting when present in both eyes is usually congenital and not significant.
39
Pulsations:
present in veins near disc as their drainage meets intermittent pressure of arterial systole; often hard to see.
40
Examination of Macula
Inspect last since bright light causes some watering, discomfort, and pupillary constriction. Ask patient to look directly into the light. Characteristics: Located 2 disk diameters temporal to the disk. Small, darker red area of the fundus. Vessels taper before reaching macula. Fovea centralis - small darker area in the center which reflects light.
41
Findings in infants and children
Fundus appears pale, and vessels are not fully developed; no foveal light reflection because macula area will not be mature until 1 year of age. Inspect fundus of young and school-age child as described in preceding section on adult. Allow child to handle equipment -\> explain why you are darkening room and that you will leave a small light on. Assure child that procedure will not hurt -\> direct child to look at an appealing picture, perhaps a toy or an animal, during examination.
42
What are some changes in aging?
Retinal structures generally have less shine -\> blood vessels look paler, narrower, and attenuated; arterioles appear paler and straighter, with a narrower light reflex. -Drusen
43
Drusen
Undigested cellular debris. Dry Atrophic (more common, but less severe) Wet Exudative/Neovascular Seen in Macular Degeneration.
44
What are the normal fundings of the fundi
red reflex present bilaterally. Discs flat with sharp margins. Vessels present in all quadrants without crossing defects. Retinal background has even color with no hemorrhages or exudates. Macula has even color.
45
Physiologic Cupping: Central
A small whitish depression in the optic disc, from which the retinal vessels appear to emerge. May be visible either centrally or toward the temporal side of the disc. Grayish spots are often seen at its base.
46
What is A small whitish depression in the optic disc, from which the retinal vessels appear to emerge. May be visible either centrally or toward the temporal side of the disc. Grayish spots are often seen at its base.
Physiologic Cupping:Central
47
Physiologic Cupping: Temporal
May be visible either centrally or toward the temporal side of the disk.
48
What are the two forms of Physiologic cupping?
Central and Temporal
49
Rings and Crescents
Seen around optic disc, Not part of the disc itself and should not be included in your estimates of disc diameter A myopic crescent is a moon-shaped feature that can develop at the temporal (lateral) border of disc (it rarely occurs at the nasal border) of myopic eyes. It is primarily caused by atrophic changes that are genetically determined, with a minor contribution from stretching due to elongation of the eyeball.
50
Medullated Nerve Fibers
Much less common, but a dramatic finding. Appears as irregular white patches with feathered margins obscuring the disc edge and retinal vessels. No pathologic significance.
51
What disorder of the eye has no pathologic significance and is a less common but dramatic finding? It appears as irregular white patches with feathered margins obscuring the disc edge and retinal vessels?
Medullated Nerve Fibers
52
Causes of Papilledema
Venous Stasis leads to engorgement and swelling 2o increased ICP (meningitis, subarachnoid hemorrhage, trauma, mass lesion)
53
Findings of Papilledema
-Color pink, hyperemic. -Often with loss of venous pulsations. -Disc vessels more visible, more numerous, curve over borders of the disc. -Disc swollen with margins blurred. -Physiologic cup is not visibl
54
What is Glaucomatous Cupping?
Increased pressure within the eye that leads to increased cupping (backward depression of the disc) and atrophy.
55
What are the findings of Glaucomatous Cupping?
-Physiologic cup is enlarged, occupying more than half of the disc’s diameter. -Retinal vessels sink in and under it, and may be displaced nasally.
56
Optic Atrophy
Death of optic nerve fibers which leads to loss of tiny disc vessels. can be caused by increased IOP.
57
What are the findings of Optic Atrophy?
What color, absence of tiny disc vessels.
58
What are the superficial retinal hemorrhage findings?
Small, linear, flame-shaped, red streaks in the fundi, shaped by the superficial bundles of nerve fibers that radiate from the optic disc. May be in clusters or linear streaking at the edges.
59
What is the common causes of Superficial Retinal Hemorrhage?
Severe hypertension Papilledema Occlusion of retinal vein
60
What are the findings of a Preretinal Hemorrhage?
Develops when blood escapes into the potential space between the retina and vitreous. Larger than retinal hemorrhages. Obscures any underlying vessels since it is anterior to retina.
61
Preretinal Hemorrhage is common in?
Sudden increased ICP.
62
What are the Deep Retinal Hemorrhage findings?
Small, rounded, slightly irregular red spots (“dot” or “blot hemorrhages”). Occur in deeper layer of retina.
63
What are the common causes of Deep retinal hemorrhage?
Diabetes
64
What are the findings of Microaneurysms?
Tiny, round, red spots seen commonly in and around the macular area. Minute dilatations of very small retinal vessels -\> too small to be seen ophthalmoscopically.
65
What are the common diseases found with Microaneurysms?
Diabetic retinopathy, other causes.
66
What is Neovascularization and what disease is it common in?
Formation of new blood bessels (looks like blood stain) Common in late, proliferative stage of diabetic retinopathy.
67
What are Soft Exudates: Cotton-Wool Patches and what disease process are they common in?
Result from infarcted nerve fibers common in hypertension.
68
What are the findings of Deep Retinal Hemorrhages?
Small, rounded, slightly irregular red spots (“dot” or “blot hemorrhages”). Occur in deeper layer of retina.
69
What are the findings of Microaneurysms?
Tiny, round, red spots seen commonly in and around the macular area. Minute dilatations of very small retinal vessels -\> too small to be seen ophthalmoscopically.
70
What are the findings of Neovascularization?
More numerous, more tortuous, and narrower. Grow into vitreous -\> retinal detachment or hemorrhage + loss of vision.
71
What are the findings of Cotton-Wool Patches
White or grayish, ovoid lesions with irregular “soft” borders. Usually smaller than the disc.
72
What are the findings of hard exudates
Creamy or yellowish, often bright lesions with well-defined “hard” borders. Small and round, but may coalesce into larger irregular spots. Clusters, circular, star-shaped patterns.
73
What are hard Exudates common in?
DM and HTN.
74
What are the findings of Drusen
Yellowish round spots. Edges may be soft or hard. May concentrate at the posterior pole.
75
What is Drusen commonly found in?
Normal aging Age-related macular degeneration
76
What is a Normal Retinal and Arteriovenous (A-V) Crossing
-Normal arterial wall is transparent. -Only column of blood within it can be seen. -Normal light reflex is narrow – one fourth the diameter of the blood column. -A vein crossing beneath the artery can be see right up to the column of blood on wither side.
77
What is Hypertensive Retinopathy?
Acute and chronic hypertensive changes may manifest in the eyes, respectively, from acute changes from malignant hypertension and chronic changes from long-term, systemic hypertension.
78
What is the inital finding in an asymptomatic patient with hypertension?
Hypertensive Retinopathy
79
What are Arteriosclerotic changes?
are chronic changes resulting from systemic hypertension. In the retina, atherosclerosis and arteriolosclerosis predominate.
80
How many Grades of Arteriolar Sclerosis are there?
4
81
What is Grade 1 Arteriolar Sclerosis?
Thickening of the vessels with slight depression of veins at AV crossings.
82
What is Grade 2 Arteriolar Sclerosis?
Definite AV crossing changes and moderate local sclerosis.
83
What is Grade 3 Arteriolar Sclerosis?
Venule beneath the arterioles is invisible.
84
What is Grade 4 Arteriolar Sclerosis?
Venous obstruction and arteriolar obliteration
85
What are some Arteriolar Changes?
In hypertension, arteries may show areas of focal or generalized narrowing. The light reflex is also narrowed. The arterial wall thickens and becomes less transparent.
86
What is Copper Wiring?
Is an Arteriolar Change. Findings include full and tortuous. Develop and increased ligh reflex with a bright coppery luster. (looks like a pale keloid)
87
What is Silver Wiring?
Is an Arteriolar change. Findings include Portion of a narrowed artery develops such an opaque wall that no blood is visible within it.
88
AV Crossing/AV Nicking
Chronic hypertension stiffens and thickens arteries. Findings: Vein appears to stop abruptly on either side of the artery. Picture: At AV crossing points (arrow,) arteries indent and displace veins.
89
What are the findings of tapering?
Vein appears to taper down on the side of the artery.
90
What are the findings of banking?
Vein appears to taper down on the side of the artery.
91
What is the Hypertensive Retinopathy Classification called, and how many classes are there?
Keith-Wagener-Barker Classification (1939). There are 4 groups.
92
What is Group 1 Hypertensive Retinopathy Classification?
Slight narrowing, sclerosis, and tortuosity of the retinal arterioles. Mild, asymptomatic hypertension.
93
What is Group 2 Hypertensive Retinopathy Classification?
Definite narrowing, focal constriction, sclerosis, and AV nicking. Blood pressure is higher and sustained. Few, if any, symptoms referable to blood pressure.
94
What is Group 3 Hypertensive Retinopathy Classification?
Retinopathy (cotton-wool patches, arteriolosclerosis, hemorrhages). Blood pressure is higher and more sustained. Clinical manifestations of headaches, vertigo, and nervousness. Mild impairment of cardiac, cerebral, and renal function.
95
What is Group 4 Hypertensive Retinopathy Classification?
Neuroretinal edema, including papilledema. Siegrist streaks, Elschnig spots. Blood pressure persistently elevated. Clinical manifestations: headaches, asthenia, loss of weight, dyspnea, and visual disturbances. Impairment of cardiac, cerebral, and renal function.
96
What are the DDs of Hypertensive Retinopathy
Branch retinal artery occlusion Branch retinal vein occlusion Central retinal artery occlusion Central retinal vein occlusion Eales Disease Ocular manifestations of HIV Optic neuropathy, anterior ischemic Papilledema Pseudopapilledema
97
What are teh findings of Hypertensive Retinopathy?
Marked A-V crossing changes along inferior vessels. Copper wiring of arterioles. Cotton-wool spot superior to disc.
98
What are the findings for Hypertensive Retinopathy?
Punctuate exudates -\> scattered and radiating from fovea forming a macular star. Two soft exudates about 1 disc diameter from disc. Flame-shaped hemorrhages sweeping toward 7 o’clock and 8 o’clock. (Looks like a sparkler in the eye)
99
What is the leading cause of new blindness in persons age 25-74 in the US?
Diabetic Retinopathy (has mild, moderate and severe)
100
What is the earliest clinical sign of diabetic retinopathy?
Microaneurysms.
101
What are teh common findings of Diabetic Retinopathy
Microaneurysms Dot and blot hemorrhages Flame-shaped hemorrhages Retinal edema and hard exudates Cotton-wool spots Venous loops and venous beading Intraretinal microvascular abnormalities Macular edema
102
Mild Nonproliferative Retinopathy?
Microaneurysms Dot and blot hemorrhages Flame-shaped hemorrhages Retinal edema and hard exudates Cotton-wool spots Venous loops and venous beading Intraretinal microvascular abnormalities Macular edema
103
Moderate Nonproliferative Retinopathy
As the disease progresses, some blood vessels that nourish the retina are blocked. Presence of hemorrhages, microaneurysms, and hard exudates. Intraretinal microaneurysms and dot and blot haemorrhages of greater severity, in one to three quadrants. Cotton wool spots, venous calibre changes including venous beading, and intraretinal microvascular abnormalities are present but mild.
104
Severe Nonproliferative Retinopathy
At least one of the following should be present: ‘Severe’ haemorrhages and microaneurysms in all four quadrants of the fundus. Venous beading, which is more marked in at least two quadrants. Intraretinal microvascular abnormalities, which are more severe in at least one quadrant.
105
Proliferative Retinopathy
Neovascularization is the hallmark. Micro-vascular pathology with capillary closure in the retina leads to hypoxia of tissue -\> hypoxia leads to release of vaso-proliferative factors which stimulate new blood vessel formation to provide better oxygenation of retinal tissue. new vessels growing on the retina = neovascularisation elsewhere (NVE) and those on the optic disc are called neovascularisation of the disc (NVD). These new vessels can bleed and produce haemorrhage into the vitreous.
106
What is the hallmark sign for Proliferative Retinopathy?
Neovascularization.
107
What Falls under Diabetic Retinopathy?
Mild Nonproliferative, Moderate Proliferative, Severe Proliferative and Proliferative.
108
What is the DDs for Diabetic Retinopathy?
Branch retinal vein occlusion Central retinal vein occlusion Macroaneurysm Macular edema, Diabetic Ocular Ischemic Syndrome Retinopathy, Diabetic (nonproliferative) Retinopathy, Hemoglobinopathies Retinopathy, Valsalva Sickle Cell Diease Terson Syndrome
109
What is the leading cause of irreversible vision loss in the industrialized world?
Age-Related Macular Degeneration (ARMD)
110
What is AMD?
is a degenerative retinal disease, presumably caused by both genetic and environmental factors.
111
What are the two types of Macular Degeneration?
Dry Atrophic (more common, but less severe) Wet Exudative/Neovascular -Findings include Drusen=Undigested cellular debris.
112
What are teh DDs for Macular degeneration
Angioid Streaks ARMD, Nonexudative Chorioretinopathy, Central Serous Choroidal Rupture Melanoma, Choroidal Multifocal Choroidopathy Syndromes Neovascular Membranes, Subretinal Neovascularization, Choroidal Presumed Ocular Histoplasmosis Syndrome Retinal Detachment, Exudative
113
What is Presbyopia?
Where the lens looses elasticity becomming hard and glasslike wihich decreases ability to change shape to accomidate for near vision. Normally happens with aging.
114
Cataracts
fibers of the lens begin to thicken and yellow. usually by the age of 70
115
What is indicative of Shade or Cobwebs with an acute onset of floaters?
Retinal Detachment.
116
What eye disorders cause no pain\>
Refractive errors, cataract and glaucoma.
117
Examination steps for Anterior Structures (Cornea, Anterior and posterior chambers (Aqueous fluid), and lens)
1. Darken the room and have the patient look off in the distance at a fixed object.
2. Switch the ophthalmoscope light and turn the lens disc to the large round beam of white light.
3. Turn lens disc to the “0” diopter (neither converges nor diverges light).
4. Hold the ophthalmoscope in your right hand to examine the patient’s right eye with your right eye; hold it in your left hand to examine the patient’s left eye with your left eye.
5. Hold the ophthalmoscope firmly braced against the medial aspect of your orbit -\> make sure you can see clearly through the aperture.
6. Stand directly in front of the patient, 10-15 inches away, and start at an angle of 15 degrees lateral to the patient’s line of vision.
●
7. Shine the beam of light onto the pupil and look for an orange glow in the pupil -\> red reflex (reflection of ophthalmoscope light off inner retina). Note any opacities.
8. Place your thumb of your opposite hand across the patient’s eyebrow.
9. Focusing the light beam on the red reflex, move inward towards the nasal aspect of the visual field.
10. Note any opacities in media -\> appear as dark shadows or black dots interrupting red reflex. Normally, none are present.
11. Progress toward person until your forehead hits your thumb.
12. Adjust diopter to bring ocular fundus into sharp focus. If you and person have normal vision, this should be at 0.
13. Moving diopters compensates for near- or farsightedness
–Use red lenses for nearsighted eyes
–Use black lenses for farsighted eyes
14. Moving in on 15-degree lateral line should bring your view just to optic disc.
15. If disc is not in sight, track a blood vessel as it grows larger and it will lead to disc.
118
Examination of the Background
Inspect sourrounding retina for lesions, note size, shape color and distriution of retinal lesions. Lesions can be measured in DD from the optic disc. Goes from ULQ, LLQ, LRQ, URQ, RMQ.
119
What should you always inspect last?
The macula since bright light causes some watering, discomfort and pupillary constriction.
