History and Examination in Ophthalmology

A) HISTORY

Besides chief complaints, other portion of history is similar to the one you prepare in internal medicine.

ocular examination1. Description of symptom (SOCRATES):

  • S – Site (Unilateral or Bilateral)
  • O- Onset
  • C – Character
  • R – Radiation (if applicable)
  • A – Aggravating and relieving factors
  • T – Timing and Duration
  • S – Severity

2. Associated symptoms (ABCDEFGs):

  • Allergic – Itch, seasonal variation
  • Blunt trauma
  • Colored halos (Acute congestive glaucoma)
  • Dryness
  • Discharge
  • Eyelids/movements
  • Floaters/flashes (Vitreous Hemorrhage/Degeneration)
  • Glare (Cataract)
  • Sticky (Mucopurulent conjunctivitis)

3. Review of Symptoms:

  • Constitutional – Fever, fatigue, night sweats
  • CNS
  • Cardiovascular – Chest pain or palpitations?
  • Dermatologic – Rash, itching
  • Endocrine – Cold or heat intolerance
  • GI – vomiting, diarrhea, constipation
  • GU – urethral discharge, hematuria
  • Hematologic – Bleeding, bruises
  • Respiratory – Shortness of breath, cough
  • Vascular – Leg pain
  • Arthralgia

4. Help seeked?

5. Contact lens wear?

B) DIFFERENTIAL DIAGNOSES OF COMMON OCULAR SYMPTOMS

1. Loss of vision or Dimunition of vision:

a. Sudden or Gradual?

SUDDENGRADUAL
PainlessPainfulPainlessPainful
Vascular occlusion (CRAO, CRVO)Acute Congestive Glaucoma (ACG)Progressive pterygiumChronic iridocyclitis
Retinal or Vitreous hemorrhageUveitisCorneal degeneration and dystrophiesCorneal ulceration
Retinal detachmentEndophthalmitisCataract 
Central Serous Retinpathy (CSR)Retrobulbar neuritisOptic atrophy 
Optic neuritisTrauma (Mechanical/Chemical)Chorioretinal degenerations 
Methyl alcohol amblyopiaTemporal arteritisARMD 
  Diabetic retinopathy 
  Refractive errors 

b. Central or Peripheral?

CentralPeripheral
Optic neuritisRetinitis pigmentosa
Tobacco amblyopiaAdvanced glaucoma
Macular hole/cyst/degenerationCompressive CNS lesion

c. Transient or Prolonged?

Amaurosis fugax (Transient loss of vision due to vascular abnormality in retina or brain)

  1. Carotid insufficiency
  2. Papilledema
  3. Giant cell arteritis
  4. Migraine
  5. Raynaud’s disease
  6. Severe Hypertension
  7. Prodromal symptom of CRAO

d. Mono/Binocular?

  • One eye – Optic nerve lesion or Intrinsic eye disease or Carotid artery branch disease
  • Two eyes – Cataracts, glaucoma, macular degeneration, brain injury, poisonings

e. Night or Day blindness?

Night blindness (Nyctalopia)Day blindness (Hemerlopia)
Vitamin A deficiencyCentral opacities of lens (Nuclear or polar cataract)
Retinitis Pigmentosa and other tapetoretinal degenerationsCentral corneal opacity
Congenital Stationary Night Blindness (CSNB)Central vitreous opacity
Pathological myopiaCongenital deficiency of cones
Peripheral cortical cataract 
Advanced case of POAG 
Choroidal dystrophies: gyrate atrophy and choroideremia 

Note: As pupil constricts in bright light, the opacity in the center will come in the path of light leading to day blindness

2. Defective vision for near only:

  • Presbyopia
  • Cycloplegia
  • Internal/Total Ophthalmoplegia
  • Insufficiency of accommodation

3. Floaters (Black spots in front of eyes that move with eye movement):

  • Vitreous hemorrhage: Retinal detachment, Retinopathy, SABE
  • Vitreous degenerations: Senile degeneration or Pathological myopia
  • Exudates in vitreous: Uveitis, Endophthalmitis

4. Photopsia/Scintillations (Flashes of light in front of eyes):

  • Posterior Vitreous Detachment (PVD)
  • Migraine
  • Retinal detachment/tear
  • Retinitis

Mechanism: Traction on vitreoretinal attachments → Retinal irritation → Electrical impulse discharged → Interpreted by brain as flashes of light

5. Dysmegalopsia (Optical illusion of size):

  • Macropsia: Miotics, Spasm of accommodation, Increased positive power of lens
  • Micropsia: Accomodative paralysis, Mydriatics, Presbyopsia, Increased negative power of lens
  • Metamorphosia (Distorted): Migraine, Macular lesions
  • Teleopsia (Far): Bilateral parietal lesion

6. Colored halos (Colored ring around lights):

  • Mucus on corneal surface: Mucopurulent conjuncitivitis
  • Corneal edema: Bullous keratopathy, Acute Congestive Glaucoma
  • Lens: Immature cataract

Mechanism: Prismatic dispersion of light in cornea/lens.

7. Glare (Difficulty to seen in bright light):

  • Diffraction of light caused by opacities in refractive surfaces: cataract

8. Photophobia (Difficulty to open eyes in normal intensity light):

  • Corneal: Corneal epithelial defect, Ulcerative keratitis, Corneal edema
  • Acute iridocyclitis

Mechanism: Stimulation of sensory nerve endings in corneal affections.

9. Diplopia (Double vision):

  • Binocular: Only when both eyes open (disappear on closure of 1 eye) and is due to problem in –
    • Nerve: CN 3,4,6 paralysis (Paralytic squint)
    • Neuromuscular junction: Myasthenia gravis
    • Extraocular muscles: Blowout fracture of orbit (muscle entrapment), thyroid disorders
    • Other: Anisometropic glass, Paradoxical diplopia
  • Uniocular: Even with 1 eye (abnormal eye) being open and is due to problem in refractive medium causing double refraction
    • Corneal: Keratoconus
    • Pupil: Double pupil
    • Lens: Subluxated lens, displaced IOL, Incipient cataract

Paradoxical diplopia: Anomalous retinal correspondence (ARC) is an adaptation to a moderate angle infantile strabismus that allows brain to accept parafoveal images from the fixing eye. If strabismus of patient with ARC is corrected by surgery or a prism, image will be displaced off the pseudofovea onto the retina that is optically perceived as being non-responding. Because, the image is displaced off the pseudofovea, the patient will see double even if the image falls on the true anatomic fovea. This is called paradoxical diplopia.

10. Red eye:

PainfulPainless
TraumaticBlepharitis
Corneal: abrasion/ulcer/keratitisConjunctivitis
Acute angle closure glaucomaInflamed pingeucula or pterygium
UveitisSubconjunctival hemorrhage
ScleritisEpiscleritis
Endophthalmitis 
Orbital pseudotumor 
Orbital cellulitis 

11. Headache:

  • Ocular causes:
    • Refractive errors
    • Extraocular muscle imbalance
    • Deficiency of accommodation
    • Convergence insufficiency
    • Ocular inflammations
    • Glaucoma
  • Non-ocular causes:
    • Neurological: Intracranial space occupying lesion, meningitis, Subarachnoid hemorrhage
    • ENT: Sinusitis, rhinitis, migraine
    • Primary headaches: Migraine, cluster headache, tension headache

C) OCULAR EXAMINATION

1. Visual Acuity (VA):

Measurement of the threshold of discrimination of 2 spatially separated targets (a function of fovea centralis).

  • Progression: Aided > Unaided > Pinhole (will improve vision with reversible refractive errors)
  • Principle: 2 distant points can be visible only when they subtend an angle of 1 min at nodal point of the eye
    1 line = 1 min i.e. 1 letter = 5 X 1 line = 5 min

a. Distant vision: Snellen’s chart test

  • Other charts: Snellen’s E chart, Landolt’s C chart, Allen’s picture chart
  • Snellen fraction = Testing distance (6m or 20ft)/Smallest line patient can read on chart
  • Why 6m? Rays of light are parallel and patient exerts minimum accommodation (Can be achieved by plane mirror at 3 m)
  • Hierarchy for low vision: Snellen acuity (6>5>4>3>2>1m) > Counting fingers (CF: 1ft > close to face) > Hand movements (HM) > Perception of light (PL) with Projection of rays (PR) in all 4 quadrants > PL negative
  • Test each eye separately

b. Near vision:

  • Charts: Jaeger’s, Roman’s, Snellen’s chart
  • Testing distance: 30 cm
  • Smallest letters which can be read is recorded as near vision
  • Normal: N6

c. Pinhole test:

  • Size: 1mm
  • Principle: Cuts off all peripheral rays and allows only central parallel beam of rays to enter eye and visual improvement in refractive errors.
  • Interpretation:
    • VA improves: refractive error which can be corrected
    • VA same: corneal and lens causes
    • VA decreases: central corneal/lens opacities, macular pathologies

2. Head Posture:

  • Elevation of chin: Ptosis, Paralysis of elevators of eyeball, Overaction of depressors
  • Depression of chin: Paralysis of depressor or Overaction of elevators of eyeball

Ocular torticollis: Tilting of head to compensate for defective ocular movement

3. Facial Symmetry:

Causes of asymmetry:

  • CN VII palsy
  • Unilateral ptosis: Increased wrinkling of forehead (overaction of frontalis on ptotic side)

4. Eyebrows:

Definition: Symmetrical collection of hair follicle son supraciliary arch

Normal:

  • Symmetrically placed on each side
  • Curved with convexity upwards, hair arranged in comma shaped

Raised: Ptotic side (Frontalis overaction)

Madarosis (loss of cilia): Leprosy, Syphilis, Hyper or hypothyroidism, Trauma

Poliosis (graying of cilia): Unilateral vitiligo, VKH syndrome (Vogt-Koyanagai-Harada Syndrome)

5. Eyelids:

Position: Normally upper lid covers 1/6 of cornea i.e. 2 mm and lower lid touches inferior limbus

  • Ptosis: > 2mm
  • Lid retraction: Limbus visible (Hyperthyroidism)

Margins: Rounded anterior border and a sharp posterior border with Lateral/Ciliary portion having Eye lashes and Medial/Lacrimal portion where eye lashes are absent

  • Entropion: Inward turning
  • Ectropion: Outward turning
  • Tylosis: Thickening
  • Epicanthus: Semicircular fold of skin covering medial canthus

Telecanthus: Increased distance between 2 medial canthi because of long medial canthal tendons

Movements: Involuntary blinks; 12-16/min

  • Increased blink: Essential blepharospasm, Reflex blepharospasm
  • Decreased blink: Lagophthalmos (Inability to close eyelids completely) i.e. CN V palsy, symblepharon

Palpebral aperture: Height 8-10 mm; Width 28-30 mm

  • All round narrow: Blepharospasm
  • Horizontally narrow: Ankyloblepharon
  • Vertically narrow: Ptosis, Phthisis bulbi, Blepharospasm
  • Vertically wide: Proptosis, Upper lid retraction

Blepharospasm syndrome: Ptosis, Blepharophimosis, Epicanthus inversus, Telecanthus

Eyelashes:

  • Normal: Upper lid – directed forwards, upwards and backwards; 100-150

Lower lid – forwards, downwards and backwards; 75-100

  • Trichiasis (misdirected cilia): trachoma, blepharitis, stye, trauma, burns
  • Distichiasis (congenital presence of abnormal posterior row of eyelashes)
  • Madarosis: Ulcerative blepharitis, leprosy, myxedema, syphilis
  • Poliosis: Sarcoidosis, sympathetic ophthalmitis, VKH syndrome

Skin:

  • Normal: Thin, smooth and elastic
  • Swellings: Chalazion, External and internal hordeolum, Lid tumors
  • Cryptophthalmos: hidden eyeball i.e. eyeball is covered by a skin layer

6. Lacrimal Apparatus:

Inspection of:

  • Lacrimal puncta: absence, eversion or stenosis
  • Skin over lacrimal sac area: redness, swelling, fistula

Regurgitation test: pressure over lacrimal sac area with thumb or index finger

  • Normal: No regurgitation of fluid/discharge
  • Positive: Chronic dacryocystitis
  • Flase negative: Chronic dacryocystitis with encysted mucocele, interal fistula, wrong method

7. Eyeballs:

Position: line joining central points of superior and inferior orbital margins just touches the cornea

  • Proptosis: forward displacement/protrusion of normal sized eyeball beyond orbital margins
  • Enophthalmos: inward displacement of the eyeball
    • Blow out fractures (loss of orbital contents)
    • Atrophy of orbital contents (Senile atrophy of fat, Irradiation of malignant orbital tumor)
    • Paralytic enophthalmos (Horner’s syndrome)
    • Post-inflammatory
  • Pseudoproptosis: eye appeared proptosed due to enlargement of eyeball
    • Buphthalmos
    • High axial myopia
    • Lid retraction
    • Enophthalmos of opposite eye

Size:

  • Normal: AP diameter 24 mm, Horizontal diameter 23.5 mm, Vertical diameter 23 mm, Circumference 75 mm, Volume 6.5 cc, Weight 7 gm
  • Increased size: High myopia, Buphthalmos
  • Decreased size: Microphthalmos, Phthisis bulbi, Atrophic bulbi

Movements:

  • Uniocular: Ductions (supra-, add-, abd-, infra-)
  • Binocular:
    • Versions: Dextro-, Levo-, Dextroelevation, Dextrodepression, Levoelevation, Levodepression
    • Vergence: Convergence and Divergence
  • Limited ocular movements: CN 3,4,6 paresis or paralysis
  • Restricted ocular movements: mass lesions outside the muscle restricting the movement of the muscle

8. Visual Axis:

Orthophoria: Normal visual axes of 2 eyes are parallel to each other in primary position and same is maintained in all positions of gaze

Squint/Strabismus: Misalignment of visual axes of eyes

  • Apparent squint or pseudostrabismus
    • Pseudoesotropia: Prominent epicanthal fold
    • Pseudoexotropia: Hypertelorism
  • Latent squint (Heterophoria)
  • Manifest squint (Heterotropia) – Concomitant or Incomitant

9. Conjunctiva:

Definition: Mucous membrane lining posterior aspect of eyelids and anterior surface of sclera

PartsMethod of Examination
Bulbar conjunctivaRetracting upper and lower lid
Palpebral conjunctiva

a.       Upper

b.      Lower

 

Eversion of upper lid (1 or 2 hand technique)

Retracting lids

Conjunctival fornices

a.       Upper

b.      Lower

 

Double eversion of upper lid

Retracting lids

Look for:

  1. Congestion: Conjunctival or Ciliary
    ConjunctivalCiliary
    Posterior conjunctival blood vesselsAnterior ciliary artery
    Diffuse (more marked on fornices)Localized (more marked in limbus)
    Bright redDusky red
    Superficial and branching vesselsDeep and radiating vessels
    Vessels move with conjunctivaVessels do not move
    On sqeezing, fills slowly from fornix to limbusOn squeezing, fills rapidly from limbus to fornices
    Blanches with 1:10000 adrenalineDo not blanch
    Eg. ConjunctivitisEg. Iridocyclitis, Keratitis
  2. Chemosis (Edema of conjunctiva):
    • Ocular inflammations: Conjunctivitis, keratitis, iritis, endophthalmitis, etc.
    • Generalized edema: CHF, angioneurotic edema
    • Decreased venous flow: Exophthalmos, Orbital pseudotumor
  3. Reddish discoloration: Subconjunctival hemorrhage (ecchymosis)
  4. Follicles and papillae
 FolliclesPapillae
DefinitionAggregation of lymphocytes which present as elevated lesions with pale center (grayish white –grains)Represent blood vessels surrounded by inflammatory cells (vascular and epithelial hyperplasia) which present as flat-topped, reddish/velvety raised areas
Common siteLower tarsal conjunctiva and Upper tarsal borderUpper tarsal conjunctiva
Common causesViral or Chlamydial infection

1.       Trachoma

2.       Acute follicular conjunctivitis

3.       Chronic follicular conjunctivitis

4.       Benign (School) folliculosis

Allergic diseases

1.       Allergic conjunctivitis

2.       Spring catarrah (VKC)

3.       Giant papillary conjunctivitis

4.       Trachoma

 

Some Common conditions of conjunctiva:

  • Degenerative conditions: Pterygium and Pingeucula
  • Conjunctival cysts and tumors:
    • Cysts: Cysticerous cyst, Retention cyst
    • Tumors: Papilloma, Squamous cell carcinoma
  • Xerosis of conjunctiva: Dry, lusterless
  • Bitot’s spot: foamy, silvery white triangular patch on bulbar conjunctiva

10. Cornea:

Size: Anterior surface has horizontal diameter of 11.7 mm and vertical diameter of 11 mm

  • Microcornea: Anterior horizontal diameter <10 mm
    • Isolated anomaly (Rare)
    • Microphthalmos (Abnormal small eyeball)
    • Nanophthalmos (Normal small eyeball)
    • Systemic associations (Dwarfism, Fetal Alcohol Syndrome)
  • Macrocornea: Anterior horizontal diameter >13 mm after 2 years of age or of adult size (11.7 mm) at birth
    • Sex linked inheritance (common in males)
    • Connective tissue disorders: Marfan’s syndrome, Ehlers-Danlos syndrome, Down’s syndrome

Shape (Curvature): Concavo-convex transparent structure resembling a watch glass with radius of curvature in the optical zone 7.8 mm anteriorly and 7 mm posteriorly. Normal corneal curvature is 44 D. It is measured by: Keratometry, Video keratography, CT, Orbscan

  • Increased curvature: Keratoconus (Cone shaped protrusion of cornea), Keratoglobus (thinning and protrusion of whole cornea)
  • Decreased curvature: Cornea plana

Surface: Smooth and shiny

  • Look at reflection of image of torch light (Distorted reflection if irregular surface)
  • Window reflex test
  • Placido’s disc test

Sensation:

Corneal reflex test: Patient is asked to look straight ahead and the cornea is touched with a cotton bud and look for blinking response. The causes of decreased corneal sensation:

  • Congenital: Congenital trigeminal anesthesia, corneal hypoesthesia
  • Pharmacological: Xylocaine
  • Pathological:
    • Ocular – Viral (HSV) infection, Conreal degeneration and dystrophies
    • Post-trauma/Surgical – Corneal scars, keratoplasty, Refractive surgery
    • Systemic – Leprosy, Diabetes

Transparency: Structures inside can be made out clearly

  • Reasons for transparency:
    • Peculiar arrangement of corneal lamellae
    • Avascularity
    • Relative state of dehydration
  • Loss of transparency: Corneal edema, Corneal ulcer, Corneal opacity, Corneal degeneration, Corneal dystrophies

11. Sclera:

Definition: White and covered by bulbar conjunctiva

Discoloration:

  • Yellowish: Jaundice
  • Bluish: Osteogenesis Imperfecta, Marfan’s syndrome, Ehler Danlos syndrome, High myopia, Buphthalmos

Staphyloma: Protrusion of thin and weak sclera lined by uveal tissue

  • Types:
    • Anterior (Cornea-iris)
    • Intercalary (Limbus-iris)
    • Ciliary (Sclera-ciliary body)
    • Equatorial (Sclera-choroid)
    • Posterior (Sclera-choroid behind equatorial region)
  • Causes: Trauma, RA, High myopia, Glaucoma

Scleral inflammation: Sectoral congestion in episcleritis and scleritis

12. Anterior Chamber:

Depth: 2.5 mm in center

  • Torch light method: Light is thrown from temporal side of limbus
    • If the illumination is seen at temporal half of the nasal limbus, anterior chamber is said to be of normal depth or not shallow
    • If nasal half of iris appears dark (eclipse sign), Anterior chamber is said to be shallow
  • Pachymetry
  • Peripheral AC depth: Slit-lamp method (Van Herick grading)
DeepPAC > ½ CT
Mild narrowPAC = ¼ to ½ CT
Moderate narrowPACT = ¼ CT
Severe narrowPAC < ¼ CT

PAC = Peripheral AC depth
CT = Corneal thickness

Causes of Shallow ACCauses of Deep AC
Acute congestive glaucomaKeratoconus/globus
HypermetropiaBuphthalmos
Intumescent cataractAphakia
Malignant glaucomaMyopia
Postoperative leaking woundPosterior dislocation of lens
 Posterior perforation of globe
  

Contents:

  • Hypopyon: Collection of pus in anterior chamber
    • Corneal ulcer
    • Iridocyclitis
    • Endophthalmitis
    • Panophthalmitis
    • Retinoblastoma (Pseudohypopyon)
  • Hyphema: Colleciton of blood in anterior chamber
    • Ocular trauma: Mechanical or surgical
    • Hemorrhagic uveitis (HZV or gonococcal)
    • Intraocular tumor
    • Spontaneous (Rubeosis iridis)
  • Aqueous flare: Collection of protein particles due to leakage from damaged blood vessels in AC
    • Iridocyclitis
Grade 
+Faint, just detectable flare
++Moderate, iris and lens detail clear
+++Marked, iris and lens details not clear
++++Fixed coagulated aqueous thin fibrin
  • Aqueous cells: Collection of inflammatory cells
    • Iridocyclitis
Cells/fieldGrade
0
1-10+
11-20++
21-50+++
>50++++
  • Inverse hypopyon: Collection of silicone oil in the AC which is used as a vitreous substitute in retinal surgeries like Retinal detachment surgery.
    • Silicone is lighter than water (collects superiorly in AC)
  • Other: AC IOL, Anteriorly dislocated lens

Angle of Anterior Chamber: Gonioscopy in patient with glaucoma

  • Not possible with slit lamp because of:
    • Overhanging sclera shelf
    • Total internal reflection of light from angle of AC

13. Iris:

Color: variable

  • Hyperchromic (darker colored iris is abnormal): Malignant melanoma, Siderosis bulbi
  • Hypochromic (lighter colored iris is abnormal): Horner’s syndrome, Fuch’s heterochromic iridocyclitis, Iris atrophy (trauma, iridocyclitis)
  • Heterochromia iridium: different color of iris in 2 eyes
  • Heterochromia iridis: different in different sectors of same eye
    • Congenital
    • Acquired: Iris atrophy (Acute congestive glaucoma, Iridocyclitis)

Pattern:

  • Disturbed/Absent: Atrophic patches in old iridocyclitis

Abnormalities:

  • Iridodonesis: tremulousness of iris due to lack of posterior support given by lens
    • Aphakia
    • Dislocation of lens
    • Hypermature shrunken cataract
  • Synechiae: Adhesion of iris to other intraocular structures
    • Anterior: structures in front of iris like corneal endothelium
    • Peripheral: iris root to trabecular meshwork (Acute Congestive Glaucoma)
    • Posterior: to lens (Total/segmental leads to Festooned pupil)
  • Persistent papillary membrane: Remnant of vascular sheath of lens seen as tags on surface of iris
  • Rubeosis iridis: Neovascularization of iris
    • Central Retinal Vein Occlusion (CRVO)
    • Diabetes Mellitus
    • Fuch’s heterochromic iridocyclitis
    • Sickle cell retinopathy
    • Anterior segment ischemia
    • Carotid artery occlusion disease
    • Neovascularization glaucoma
  • Pseudoexfoliation of iris: Glaucoma
  • Nodules:
    • Granulomatous uveitis (Koeppe’s and Bussaca’s nodules)
    • Melanoma of iris
    • Tuberculoma
    • Gumma
  • Coloboma of iris: Absence of tissue due to failure of closure of embryonic fissure
    • Typical (Inferonasal quadrant) vs Atypical (Other position)
    • Complete (Extending from iris to optic nerve) vs Incomplete

14. Pupil:

Definition: Aperture in the center of the iris

Number: Polycoria (>1 pupil)

Site: Normally center or slightly nasal

Size: 3-4 mm

 Miosis (Constricted pupil)Mydriasis (Dilated pupil)
PhysiologicalOld age (Senile rigid mitotic pupil)

Sleep

Exposure to bright light

Exposure to dim light
PharmacologicalParasympathomimetics (Pilocarpine, Systemic morphine)Parasympatholytics (Atropine, Tropicamide, etc.)

Sympathomimetics (Phenylephrine)

PathologicalIridocyclitis

Horner’s syndrome

Pontine hemorrhage

Hyperpyrexia

Acute Congestive Glaucoma

Absolute Glaucoma

Optic atrophy

CN III paralysis

Total retinal detachment

Sympathetic stimulation

Shape: round

  • Irregular due to synechiae in cases of iridocyclitis
  • Festooned pupil: irregular dilated pupil seen after effect of mydriatics in presence of posterior synechiae

Color: black/grayish black (depends on structure behind the pupil)

  • Grayish white: Immature cataract
  • Pearly white: Mature cataract
  • Milky white: Hypermature cataract
  • Jet black: Aphakia
  • Jet black with shining reflexes: Pseudophakia
  • Leukocoria (Whitish papillary reflex): Congenital cataract, Retinoblastoma, Persistent hyperplastic primary vitreous, Retrolental fibroplasia, Toxocara endophthalmitis, Coat’s disease

Pupillary reactions:

  • Light reflex: In a dimly illuminated room, light is brought from the temporal side and palm of hand or cardboard
    • Direct: Look for constriction in same eye
    • Indirect/Consensual: Look for constriction on opposite eye
  1. Near reflex: Patient looking at a far object is asked to look finger tip held 15 cms from eye
    • 2 components: Convergence reflex and Accomodation reflex

15. Lens:

Position: Patellar fossa suspended by suspensory ligaments of ciliary processes

  • Subluxation (Partial displacement)
    • Congenital simple ectopia lentis
    • Ectopia lentis with systemic anomalies: Marfan’s syndrome, Homocystinuria, Weil-Marchesani syndrome, Ehlers-Danlos syndrome
    • Trauma
    • Hypermature cataract
  • Dislocation (Complete displacement):
    • Anterior: lens in anterior chamber
    • Posterior: lens in vitreous cavity
    • Floating lens: lens nutans
    • Fixed to retina: lens fixate

Shape: Biconvex with anterior surface of lens curved than posterior

  • Lenticonus: cone shaped bulge seen on
    • Anterior capsule (Anterior lenticonus): Alport syndrome
    • Posterior capsule (Posterior lenticonus): Lowe’s syndrome
  • Microspherophakia: small spherical lens
    • Weil-Marchesani syndrome
    • Marfan syndrome

Color: grayish black/black

  • Transparency: lost in cataract
    • Complicated cataract: Breadcrumb appearance
    • Diabetes mellitus: Snowflake opacities
    • Wilson’s disease: Sunflower cataract
    • Traumatic cataract: Rosette cataract

Purkinje image test: When light is shown on eye, 4 purkinje images are formed because of 4 reflecting surfaces i.e. anterior and posterior surfaces of cornea and lens.

  • Aphapkia (no lens): 3rd and 4th images are absent
  • Mature cataract (Posterior surface not reached): 4th image absent
  • Normal, immature cataract, Pseudophakia: All 4 images present
  • 2 corneal surface and anterior surface of lens (Convex) forms Virtual and erect image
  • Posterior lens surface (Concave) forms Real, inverted and minified image

 

16. Intraocular Pressure (IOP):

Digital tonometry:

  • Ask patient to look downwards
  • Perform fluctuation test of eyeball at upper eyelid with both the index fingers
  • Interpretation: Increased IOP (firm and hard); Decreased IOP (soft)

Indentation (Schiotz) tonometry

17. Ophthalmoscopy

5 thoughts on “History and Examination in Ophthalmology

  1. Best for ug opthal viva n clinical postings… very helpful to tabulate history n proceed for examination

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