Physical Examination of the Eyes and History Taking (trans 5)

Question 1

HISTORY TAKING
Chief Complaint
 “There is only one chief, all the rest are mere Indians.”

Answer 1

 Just ask for the MOST essential complaint at that particular time, pertaining to your field of expertise (in this case, ophthalmology)

Question 2

Chief Complaint
Scenario:
Doctor (MD): Lola ano po ba ang nararamdaman ninyo? Patient (Px): Malabo po yung aking paningin eh, tapos masakit yung ulo ko, tapos nahihilo ako.

Answer 2

o The most likely chief complaint in this scenario is the blurring of vision

Question 3

Onset, Duration, and Severity of Symptoms

Answer 3

 Presence of high index suspicion should be practiced by the physician
 If patient reports a change in vision, pursue related details
 Onset: Sudden of gradual?

Question 4

Onset, Duration, and Severity of Symptoms
Scenario:
MD: Kailan nyo pa po naramdaman ito?
Px: Mga tatlong araw na po.
o Acute onset; condition is chronic if it persists for more than two weeks

Answer 4

MD: Paano nagsimula ito?
Px: Nagkusot po ako ng mata tapos sumakit na.
MD: Gaano kasakit po ba ito?
Px: Sa sobrang sakit po, nasuka ako.
o The pain center in the brain is adjacent to the vomiting center. When the pain center sends off stimuli, the vomiting center will be affected causing a reaction in the center and the patient will vomit.

Question 5

Associated Signs and Symptoms
Usual Associated Signs and Symptoms:
o Redness
o Pain
o Photophobia: condition wherein bright light hurts the eyes
- When the patient looks at the light, she feels pain in her eyes. If the photophobia is caused by a problem in her right eye, ask the patient to cover the involved eye and let her use the left eye to look at the light. If the patient still feels pain, the condition might be deeper in location

Answer 5

o Discharge
 Purulent: bacterial infection
 Mucoid: viral infection
 Tearful/watery: allergic in origin
o Double Vision

Question 6

Consultation and Treatment

Before the consultation, the patient may have self-medicated according to certain beliefs

Answer 6

Scenario:
MD: Nagpa-check up ka ba sa doctor? May gamot ka bang ipinitak o ininom?
Px: Sabi ng kapitbahay ko baka sore eyes kaya nilagyan ko ng gatas ng ina. Sabi nga ng kumare ko, ihi daw ang dapat ipatak.
o Why breastmilk? Aside from immunoglobulins, it contains estrogen that has an astringent effect, resulting in the disappearance of the redness. It also whitens the eye due to its physical appearance, and it promotes vasoconstriction of the blood vessels in the eyes thereby reducing redness.
- Adverse event: Ocular pressure might rise, however, and patient could develop glaucoma.
o Why women’s urine? It also contains high levels of estrogen that can decongest the blood vessels in the eye.
- Adverse event: An infection like gonorrhea or other gonococcal infections can be caught by the patient.

Question 7

Aggravating and Alleviating Factors

Answer 7

Scenario:
MD: May ginagawa po ba kayo na nakakapagpalala at nakakapagpawala ng sakit?
Px: Doc kapag umuubo o umiiri ako,lalong sumasakit. Pero pag umiinom ako ng Ponstan gumagaan nang konti ang pakiramdam ko.
o When the patient coughs or strains, the intraocular pressure rises, which results to PAIN. The patient may also feel severe headache.
o Paracetamol may not be effective in relieving severe pain, but it is given to patients with renal problems.
o Mefenamic acid (Ponstan) is an NSAID used as an analgesic for mild to moderate pain. Its usual dose is 1 tablet (500 mg) q4h (8am, 12nn, 4pm, 8pm) taken with meals as needed for pain.

Question 8

Other Pertinent Questions

Answer 8

 Systemic signs and symptoms
 History of Diabetes Mellitus (DM), Hypertension (HPN), cardiac disease, and trauma
 Any intake of drugs: e.g. Clopidogrel, Aspirin, Warfarin (Coumadin) or other blood thinners may cause patients to bleed out during surgical procedures.
 Prior surgeries and treatments: Check whether patient has undergone intraocular surgeries, such as cataract removal

Question 9

INSPECTION/EYEBALLING

Answer 9

 Start off from anterior to posterior. Inspect the eyelashes, lids and palpebral openings and note for abnormalities.
 Upper eyelashes grow downwards then upwards while lower eyelashes grow upwards then downwards
 Inspect the position and alignment of the eyes, the eyebrows, eyelids, lacrimal apparatus, conjunctiva, sclera, cornea, iris and lens

Question 10

INSPECTION/EYEBALLING: Entropion vs. Ectropion

 Entropia: inward rolling/turn of the eyelid margins causing the eyelashes to touch the cornea

Answer 10

Ectropion: lower eyelid margin is pulled away and is no
longer protecting the eye.
o Due to aging, excessive sun exposure and the effects of gravity on the skin
o It could also be iatrogenic as from an improperly sutured laceration

Question 11

INSPECTION/EYEBALLING: Trichiasis vs. Distichiasis
Trichiasis: eyelashes that grow back towards the eye
touching the cornea or conjunctiva.
o Usually due to a lid abnormality.
o The lashes touch the eye.

Answer 11

Distichiasis: abnormal growth of an eyelash from the duct of the Meibomian gland at the eyelid margin. A row of eyelashes grow inward while a row of normal eyelashes grow outward.

Question 12

INSPECTION/EYEBALLING: Ptosis vs. Proptosis
Ptosis: “lid lag”
o The upper eyelid or lower eyelid is drooping.
o Compare bilaterally, and evaluate to what degree the eyelid covers the eye. Note the quality, consistency or appearance.

Answer 12

Proptosis: the globe/eye is displaced outward and forward as a result of cyst, tumor or lesion.
o This is a PASSIVE protrusion of the globe
o Though some literature say Proptosis and Exopthalmos are used interchangeably, these two should be differentiated. Exophthalmos is the ACTIVE protrusion of the globe and is often due to a disease in the thyroid. (E.g. Grave’s disease/hyperthyroidism.)

Question 13

INSPECTION/EYEBALLING: Comparison between Proptosis and Exopthalmos
Proptosis
Cause: Cyst/tumor Inflammation Trauma
Protrusion: Usually below 18mm

Answer 13

Exopthalmos
Cause: Endocrinal (such as Grave’s disease)
Protrusion: Above 18 mm

Question 14

INSPECTION/EYEBALLING: Strabismus and Hirschberg Test
Hirschberg test - Ask the patient to look straight ahead and shine a light on the patient’s eyes using a penlight. Normally, the light’s reflection should fall on both central portions and exactly at the same point/level (symmetric) of the two cornea

Answer 14

o Orthophoria: normal condition of balance of the ocular muscles (‘straight’ gaze); seldom encountered because most people have a small latent deviation (heterophoria).
o Strabismus: abnormal condition wherein the measurement for both eye differs (misalignment of the eyes)
o Esotropia: the ray of light will fall centrally on one eye and nasally on the other eye (inward turning)
o Exotropia: the ray of light will fall centrally on one eye
and temporally on the other eye (outward turning)

Question 15

EIGHT-PART EYE EXAM

Answer 15

a. Visual Acuity
b. External Eye Exam
c. Pupillary Exam
d. Ocular Motility
e. Tonometry
f. Visual Field Examination
g. Slit Lamp Biomicroscopy
h. Ophthalmoscopy/Funduscopic Examination

Question 16

EIGHT-PART EYE EXAM - Visual Acuity

 Take the VA first before any manipulation of the eye.

Answer 16

1. snellen chart
2. E Chart
3. Counting fingers
4. Hand movement
5. Light perception
6. Numeric/Number Chart
7. Picture chart
8. Jaeger chart - for near vision
9. Early treatment for diabetic retinopathy study chart (ETDRS) - commonly used nowadays

Question 17

EIGHT-PART EYE EXAM - Visual Acuity
Snellen chart
Used for far vision testing in literate patients.
o Give your patient some leeway when they’re unable to pronounce a letter correctly, especially since not all Filipinos are adept at the English vernacular. They are not illiterate.

Answer 17

By convention, the test is done on the right eye (OD or Oculus Dexter) before the left (OS or Oculus Sinister).
o EXCEPTION: If the patient has a specific complaint on the left eye, you start with the left.

Question 18

EIGHT-PART EYE EXAM - Visual Acuity
Snellen chart
Test without and with glasses/correction.
o Test the patient without correction first.
o No need to ask the patient to remove contact lenses.
o When recording the results, indicate which eye and write “with correction” or “with contact lens”.

Answer 18

 Record the number of the line which the patient can read COMPLETELY (e.g. If the patient can only read up to the third line, write “20/70”).
 If the patient can read the next line but not completely, record it as “+”
o If the patient can read up to the third line completely and only two letters from the fourth line, write “20/70+2”.
 If the patient cannot see the biggest letter, ask the patient to move closer to the chart until he/she is able to read the first letter.
o In the department, this is done by moving the patient 5 feet closer every time.
o Change the first number of the visual acuity grade according to how far the patient is from the chart.
o If the patient is 15 feet away from the chart, write 15/200.
o If the patient still cannot see the biggest letter at 5 feet, proceed to the counting fingers test

Question 19

EIGHT-PART EYE EXAM - Visual Acuity

E Chart

Answer 19

 Used for far vision testing of illiterate patients.
 May also be used for children
 Ask the patient where the E is pointing towards.
o Kung tinidor po ito, saan nakaturo?

Question 20

EIGHT-PART EYE EXAM - Visual Acuity

Counting fingers

Answer 20

 Ask the patient to count how many fingers are raised
 Write CF if the patient is able to count.
 If not proceed to hand movement test.

Question 21

EIGHT-PART EYE EXAM - Visual Acuity

Hand movement

Answer 21

 Ask the patient if he/she can perceive movement of your hand
 Write HM if hand movement is seen.
 If not, proceed to light perception test.

Question 22

EIGHT-PART EYE EXAM - Visual Acuity

Light perception

Answer 22

 Shine a penlight on the patient’s eyes and ask if he/she can see it
 If the patient cannot see the light, write NLP or negative light perception.
 NEVER write blind!

Question 23

EIGHT-PART EYE EXAM - Visual Acuity
Numeric/Number Chart
 For patients who are not adept in Filipino or English but can read numbers.

Answer 23

Picture chart
 May be used for children.
 Ask the child to sit on the mother’s / guardian’s lap.
 Tell the patient what each picture is first if he/she is having a hard time identifying it.

Question 24

EIGHT-PART EYE EXAM - External Eye Exam

Answer 24

 Examine the immediately visible structures of the eye, including structures around the eye such as the eyelid.

Question 25

EIGHT-PART EYE EXAM - External Eye Exam

Iatrogenic ectropion

Answer 25

 A gray line that is a result of an improperly sutured laceration.
 Abnormal eversion of the lid margin away from the eyeball

Question 26

EIGHT-PART EYE EXAM - External Eye Exam
External hordeolum (“kuliti”)

Answer 26

 There are 40 sweat glands on the upper lid, and 20 on the lower lid
 There is a possibility of multiple hordeolum. If so, ask if the patient has diabetes or has a family history of DM, which is correlated with this condition.
 Usually due to Staphylococcus.
 Skin of the eyelids are the thinnest skin of the body, so be careful!

Question 27

EIGHT-PART EYE EXAM - External Eye Exam
Chalazion
 Chronic granulomatous inflammation of the Meibomian gland.

Answer 27

It may become acutely inflamed but, unlike a sty, usually points inside the lid rather than on the lid margin
o Cannot be dissolved by any topical or oral antibiotics as it is already encapsulated
o Management: Incision and curettage

Question 28

EIGHT-PART EYE EXAM - External Eye Exam

Herpes Zoster ophthalmicus

Answer 28

 Occurs when the Varicella-Zoster virus is reactivated in the ophthalmic division of the trigeminal nerve
 Lesion at the tip of the nose: very likely that there is ocular involvement (by affectation of nasociliary [ciliary body of the eye] ganglion); causes photophobia (bright light hurts the eye)
 Never crosses the midline; painful

Question 29

EIGHT-PART EYE EXAM - External Eye Exam
Conjunctival Injections
 Blood vessels coming from the periphery towards the center

Answer 29

o Tortuous: blood vessels turn white when decongestant is instilled
o Circumcorneal (around the limbus): may indicate deeper infection or inflammation (iridocyclitis)

Question 30

EIGHT-PART EYE EXAM - External Eye Exam

Viral Conjunctivitis – “Sore eyes/ Pink-eye”

Answer 30

 Most common cause of a red, irritated eye
 With minimal pain and slight reduction in visual acuity
 Adenovirus infection is the most common viral etiology

Question 31

EIGHT-PART EYE EXAM - External Eye Exam

Graves’s Disease

Answer 31

 Hypertrophy of recti muscles; puffiness of the lower lids

 Can be controlled with medication

Question 32

EIGHT-PART EYE EXAM - Pupillary Exam
 Tests for the ability of the pupillary constriction (Miosis) upon flash of light from the side of the eye
 Allows the examiner to see the following structures:
Cornea, anterior chamber, iris, lends

Answer 32

Miosis
o Constriction of the pupils
o Pupillary size becomes smaller: 3-4mm
o Indicative of corneal edema
o Increased intraocular pressure

Question 33

EIGHT-PART EYE EXAM - Pupillary Exam
 Test for Relative Afferent Pupillary Defect (RAPD)
 In dim room light, note the size of the pupils. After asking the patient to gaze into the distance, swing the beam of a penlight back and forth from one pupil to the other, each time concentrating on pupillary size and reaction (normally pupil constricts) in the eye that is lit (direct light reflex). The unlit eye must also constrict (consensual reflex).
 There should be equal constriction of both eyes. If there is a difference, it suggests a “relative” defect.
 Normal report in the clinic should read: Pupils equally reactive to light and accommodation

Answer 33

Marcus Gunn pupil
o If the pupil dilates when the light illuminates it, a relative afferent pupillary defect is present and indicates an optic nerve problem, severe retinal pathology, or brain lesion

Question 34

EIGHT-PART EYE EXAM - Ocular Motility
 Tests for extra-ocular muscle movements
 Following movements

Answer 34

Ask the patient to look straight ahead then follow the examiner’s finger
o 2 methods of finger movements: H system and Cross and all angles
o if the examiner suspects the patient has strabismus, cover one eye and perform the steps above

Question 35

EIGHT-PART EYE EXAM - Ocular Motility

Types of Strabismus

Answer 35

1. Esophoria vs. Esotropia

2. Exophoria vs. Exotropia

Question 36

EIGHT-PART EYE EXAM - Ocular Motility
Esophoria vs. Esotropia
Esophoria
 Latent medial inward deviation of the globe in one or both eyes
 Ask the patient to look straight ahead, cover one eye, then open alternately. See if the eye moves

Answer 36

Esotropia
 Medial inward deviation of the globe in one eye due to extraocular muscle imbalance
 Crossed-eyed appearance
 Common in infancy and childhood

Question 37

EIGHT-PART EYE EXAM - Ocular Motility
Exophoria vs. Exotropia
Exophoria
 Latent lateral outward deviation of the globe in one or both eyes
 Common in infancy and childhood

Answer 37

Exotropia
 Lateral outward deviation of the globe in one eye due to extraocular muscle imbalance
 Light from Hirschberg test will fall on nasal limbus

Question 38

EIGHT-PART EYE EXAM - Tonometry
 Used in measuring intraocular pressure (IOP)
 Normal IOP: 12-20mmHg; Average: 14-16mmHg
 Important in determination of glaucoma in patients

Answer 38

1. Digital Tonometry
2. Schiotz Tonometry
3. Goldmann Applanation Tonometry

Question 39

EIGHT-PART EYE EXAM - Tonometry
Digital Tonometry
 Crude and inefficient but useful

Answer 39

Procedure:
1. Ask your patient to look down
2. Alternately and lightly press your two index fingers
against the cornea while the remaining fingers stay on the side of the face.
3. Patient must not close his/her eyes because of Bell’s phenomenon: reflex movement of the eyes up and out in response to forced eye closure, where the eyes may elevate and intraocular pressure cannot be accurately measured.
If it feels like touching the:
o Tip of the Nose – Normal IOP
o Glabella – High IOP (possible glaucoma)
o Lips – Low IOP

Question 40

EIGHT-PART EYE EXAM - Tonometry
Schiotz Tonometry
 Uses a plunger to gently push down the cornea
 Needs application of anesthetic

Answer 40

Goldmann Applanation Tonometry
 Most sensitive to IOP
 Measures flattening of the cornea
 Apply anesthesia and flourescein dye. Uses a small probe to gently flatten part of the cornea to measure eye pressure and microscope called a slit lamp to look at the eye.

Question 41

EIGHT-PART EYE EXAM - Visual Field Examination
 The visual field is the area that is visible at any one point in time
Examination aims:
o To see whether this field is intact through measuring sensitivity; and
o To test the ability to detect light thresholds at different locations

Answer 41

 Abnormal field can indicate a problem in the visual pathway.
 If defect is detected by screening, further evaluation is conducted by manual or automated procedures known as perimetry

Question 42

EIGHT-PART EYE EXAM - Confrontation Test
 Valuable technique for early detection of lesions in anterior and posterior visual pathway.
 For best results, combine two techniques: the static finger wiggle test and the kinetic red target test
The Static Finger Wiggle Test
1. Ask patient to look with both eyes into your eyes.
2. As you return your gaze to your patient’s gaze, place your hands about 2 feet apart, lateral to your patients ears.
3. Wiggle both your fingers simultaneously, and bring them slowly forward.
4. At each position, ask the patient to tell you as soon as he/she can see finger movement.
5. if you find a defect, establish its boundaries. Test one eye at a time

Answer 42

The Kinetic Red Target Test
1. Facing the patient, move a 5 mm red-topped pin inward from beyond an imaginary boundary of each quadrant along a line bisecting the horizontal and vertical meridians.
2. Ask the patient when the pin first appears to be
red.
**Automated Perimetry
 Done in the clinics
 Advanced form of confrontation exam

Question 43

EIGHT-PART EYE EXAM - Slit Lamp Biomicroscopy

Answer 43

 Examines the anterior segment of the eye on frontal structures and posterior segment
 Corneal Thickness: Center -0.5mm
 At the side/ limbus: 1mm thick

Question 44

EIGHT-PART EYE EXAM - Ophthalmoscopy/Funduscopic Examination
 Examine the posterior structure of your patients eye without dilating their pupils
 To examine the periphery, ophthalmologists dilate the pupils with mydriatic drops unless contraindicated.

Answer 44

1. Direct Ophthalmoscopy
    Monocular examination
    Welch-Allyn (WA) Conventional Head, WA Panoptic Head 15x magnification
2. Indirect Ophthalmoscopy

Question 45

EIGHT-PART EYE EXAM - Ophthalmoscopy/Funduscopic Examination
Direct Ophthalmoscopy
 Head of ophthalmoscope is structured so that it will conform to the orbit.
 Vital in assessing overall ocular health in diagnosing and monitoring specific optic nerve, retinal, neurological and systemic disorders.
 Examiner’s left eye should be used to assess patient’s left eye, same for the other side.

Answer 45

Procedure:

1. Examine the retinal blood vessels.
2. Ask the patient to look at the desired direction and then move it to the opposite direction. This should be done in 4 directions by following them: Supratemporal, supranasal, Inferotemporal, Inferonasal
3. Examine the macula by asking the patient to look at the light. You will find two optic disc diameters away from the optic disc. It would be the area which is dense
4. While examining a foreign body, if it moves against the movement of the examiner, it is in the posterior of the lens. If it moves together with the examiner, it is anterior to the lens. If it does not move, the opacity is in the lens

Question 46

EIGHT-PART EYE EXAM - Ophthalmoscopy/Funduscopic Examination

Indirect Ophthalmoscopy

Answer 46

 Difference between direct and indirect ophthalmoscopy is the presence of an intervening lens in between.
 Shows a virtual image that is inverted in order to give a wider view of the retina
 Magnification: 3.5x, which enables the optic disc blood vessels and the maculae