Site icon Epomedicine

History and Examination in Ophthalmology

Epomedicine
Tweet FB Share Pin It

A) HISTORY

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

1. Description of symptom (SOCRATES):

2. Associated symptoms (ABCDEFGs):

3. Review of Symptoms:

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?

SUDDEN GRADUAL
Painless Painful Painless Painful
Vascular occlusion (CRAO, CRVO) Acute Congestive Glaucoma (ACG) Progressive pterygium Chronic iridocyclitis
Retinal or Vitreous hemorrhage Uveitis Corneal degeneration and dystrophies Corneal ulceration
Retinal detachment Endophthalmitis Cataract  
Central Serous Retinpathy (CSR) Retrobulbar neuritis Optic atrophy  
Optic neuritis Trauma (Mechanical/Chemical) Chorioretinal degenerations  
Methyl alcohol amblyopia Temporal arteritis ARMD  
    Diabetic retinopathy  
    Refractive errors  

b. Central or Peripheral?

Central Peripheral
Optic neuritis Retinitis pigmentosa
Tobacco amblyopia Advanced glaucoma
Macular hole/cyst/degeneration Compressive 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?

e. Night or Day blindness?

Night blindness (Nyctalopia) Day blindness (Hemerlopia)
Vitamin A deficiency Central opacities of lens (Nuclear or polar cataract)
Retinitis Pigmentosa and other tapetoretinal degenerations Central corneal opacity
Congenital Stationary Night Blindness (CSNB) Central vitreous opacity
Pathological myopia Congenital 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:

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

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

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

5. Dysmegalopsia (Optical illusion of size):

6. Colored halos (Colored ring around lights):

Mechanism: Prismatic dispersion of light in cornea/lens.

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

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

Mechanism: Stimulation of sensory nerve endings in corneal affections.

9. Diplopia (Double vision):

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:

Painful Painless
Traumatic Blepharitis
Corneal: abrasion/ulcer/keratitis Conjunctivitis
Acute angle closure glaucoma Inflamed pingeucula or pterygium
Uveitis Subconjunctival hemorrhage
Scleritis Episcleritis
Endophthalmitis  
Orbital pseudotumor  
Orbital cellulitis  

11. Headache:

C) OCULAR EXAMINATION

1. Visual Acuity (VA):

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

a. Distant vision: Snellen’s chart test

b. Near vision:

c. Pinhole test:

2. Head Posture:

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

3. Facial Symmetry:

Causes of asymmetry:

4. Eyebrows:

Definition: Symmetrical collection of hair follicle son supraciliary arch

Normal:

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

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

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

Movements: Involuntary blinks; 12-16/min

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

Blepharospasm syndrome: Ptosis, Blepharophimosis, Epicanthus inversus, Telecanthus

Eyelashes:

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

Skin:

6. Lacrimal Apparatus:

Inspection of:

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

7. Eyeballs:

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

Size:

Movements:

  • 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

9. Conjunctiva:

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

Parts Method of Examination
Bulbar conjunctiva Retracting 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
    Conjunctival Ciliary
    Posterior conjunctival blood vessels Anterior ciliary artery
    Diffuse (more marked on fornices) Localized (more marked in limbus)
    Bright red Dusky red
    Superficial and branching vessels Deep and radiating vessels
    Vessels move with conjunctiva Vessels do not move
    On sqeezing, fills slowly from fornix to limbus On squeezing, fills rapidly from limbus to fornices
    Blanches with 1:10000 adrenaline Do not blanch
    Eg. Conjunctivitis Eg. 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
  Follicles Papillae
Definition Aggregation 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 site Lower tarsal conjunctiva and Upper tarsal border Upper tarsal conjunctiva
Common causes Viral 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:

10. Cornea:

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

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

Surface: Smooth and shiny

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:

Transparency: Structures inside can be made out clearly

11. Sclera:

Definition: White and covered by bulbar conjunctiva

Discoloration:

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

Scleral inflammation: Sectoral congestion in episcleritis and scleritis

12. Anterior Chamber:

Depth: 2.5 mm in center

Deep PAC > ½ CT
Mild narrow PAC = ¼ to ½ CT
Moderate narrow PACT = ¼ CT
Severe narrow PAC < ¼ CT

PAC = Peripheral AC depth
CT = Corneal thickness

Causes of Shallow AC Causes of Deep AC
Acute congestive glaucoma Keratoconus/globus
Hypermetropia Buphthalmos
Intumescent cataract Aphakia
Malignant glaucoma Myopia
Postoperative leaking wound Posterior dislocation of lens
  Posterior perforation of globe
   

Contents:

Grade  
+ Faint, just detectable flare
++ Moderate, iris and lens detail clear
+++ Marked, iris and lens details not clear
++++ Fixed coagulated aqueous thin fibrin
Cells/field Grade
0 –
1-10 +
11-20 ++
21-50 +++
>50 ++++

Angle of Anterior Chamber: Gonioscopy in patient with glaucoma

13. Iris:

Color: variable

Pattern:

Abnormalities:

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)
Physiological Old age (Senile rigid mitotic pupil)

Sleep

Exposure to bright light

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

Sympathomimetics (Phenylephrine)
Pathological Iridocyclitis

Horner’s syndrome

Pontine hemorrhage

Hyperpyrexia

 Acute Congestive Glaucoma

Absolute Glaucoma

Optic atrophy

CN III paralysis

Total retinal detachment

Sympathetic stimulation

Shape: round

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

Pupillary reactions:

  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

Shape: Biconvex with anterior surface of lens curved than posterior

Color: grayish black/black

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.

  • 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:

Indentation (Schiotz) tonometry

17. Ophthalmoscopy

Exit mobile version