Examination of the Eye
What associated sxs would we ask about?
-HA -dizziness -vertigo -pain -dc -photophobia
Gradual vision loss
-aging -cataracts -glaucoma -HIV - CMV -AI disease -DM -congential -macular degeneration -neoplasm -pseudeotumor cerebri (AKA idiopathic intracranial HTN)
What questions do you want to ask about visual disturbances?
-blurred vision/cloudy vision -tunnel vision -visual field loss -loss of central vision -flashes of light or spots -floaters -vail or curtain is coming down
Ptosis
-drooping one upper eyelid Common causes: Horner's syndrome, Bell's palsy
Sudden vision loss
-retinal detachment -vitreous hemorrhage -central retinal a. occlusions -CVA (stroke) -trauma
Steps for how to use the ophthalmoscope (6)
1. Darken the room. 2. Turn the lens disc to 0 diopter. 3 Hold the ophthalmoscope in your right hand to examine the right eye and viceversa. 4. Brace the scope against your eye and about 15-20 degrees lateral to the patient. 5. Shine the light into the pupil and find the red reflex. 6. Place your thumb of your other hand on the patient's eyebrow, keeping the light focused on the red reflex, move in with the scope maintaining the 10-20 degree angle.
Documentation of visual acuity: Recording visual acuity
20/20 - Normal Vision 20/100 - What a normal visual acuity person (20/20) can see at 100 ft.
EOM
Actions of the muscle
Bell's palsy
CN VII can be entire face if central = spares forehead
The red eye
Ciliary injection - inflammation of the radiating vessels around the limbus. Very painful, vision affected. Can be a ocular emergency.
Conjunctiva and sclera
Conjunctiva - clear mucus membrane which covers the eye Bulbar conjunctiva - covers the anterior eye Palpebral conjunctiva - lines the eyelids
Pupillary reaction to light
Direct Reaction - Constriction of the same pupil Consensual Reaction -Constriction of the opposite pupil Accommodation - Change in pupil and lens for near and far objects (different neuro pathway) Convergence - Eyes look inward to focus on a near object
Ocular anatomy diagram 2 answers
Don't look directly in, looking for the disc at a 20 degree angle. Disc doesn't have any light sensative cells in it If you go straight in you will hit the macula and the pt will shut down
Eye exam
Evaluate each eye separately, then together. Evaluate with and without corrective lenses. Important to document visual acuity. Example: With glasses (far) O.D. 20/40 O.S. 20/20 O.U. 20/20 without glasses (far) O.D. 20/100 O.S. 20/80 O.U. 20/80
Documentation of visual acuity: near and far vision
Far vision - Snellen eye chart 20 feet away Near vision - Hand held card, 14 inches Mechanical Vision Tester Titmus Vision Tester Any available print - newspaper or magazine
Open ended eye hx questions
How is your vision? Are you having any trouble with your vision? Is your vision blurred? Difficulty seeing near or far objects? Is there a change in your vision? Sudden? Gradual?
Hypertensive changes
Hypertensive changes of the artery. Focal or generalized narrowing - the arterial wall thicken and light reflex is narrowed.
Glaucomatous cupping
Increased intraocular pressure Causes increased disc cupping. The physiologic cup is enlarged occupying more than half of the Disc's diameter.
Cornea, lens, iris, and pupils
Inspect with oblique lighting - evaluate for opacities of the cornea and lens. Pupils - evaluate size, shape and symmetry of the pupils Can shine a tangential light to get a shadow
Anatomy of the fundus answers
L eye
Anatomy of the fundus labeling
Left eye
How to examine the optic disc and retina
Locate the optic disc first. It is medial. Bring the optic disc into sharp focus with the lens diopter adjustment if needed. Identify the following: a. Clarity of the disc margin b. Color of the disc c. Central physiologic cup A small whitish depression within the optic disc.
Color blindness test
Most common is red green blindness
External exam of eye lids
Palpebral fissure - normal width, widened or narrow Edema Lesions - styes, chalazion Blepharitis - inflamed lid margins Entropion and Ectropion eye lids (can be surgically corrected)
Visual pathway lesions
Pituitary gland lives at the optic chiasm if tumor can push on this -> bitemporal hemianopsia
External exam of eyes
Position and Alignment of the Eyes Are the eyes straight and without deviation
PERRLA
Pupils equal, round, reactive to light and accomodation
External exam of eyebrows
Quantity and distribution Underlying skin Scaling, rashes, ulcerations
Visual field testing (confrontation)
Stand at the same level as the patient. Cover opposite eyes. Bring fingers in from 4 directions. North/South/East/West
Eye exam steps
Visual Acuity Color blindness Extra-ocular movement Pupillary reflexes Visual field testing External examination - surrounding structures Conjunctiva and sclera Cornea, lens and pupil The ophthalmoscopic examination
How would you record an eye exam in your SOAP note?
Visual Acuity - With corrective lenses O.D. 20/40 O.S. 20/20 O.U. 20/20 without corrective lenses O.D. 20/100 O.S. 20/80 O.U. 20/80 Visual fields: Intact by confrontation No visual field defects External: Symmetrical alignment w/o deviation Eyebrows - w/o scaling or hair loss Eye lids - w/o edema or inflammation Conjunctiva - pink and w/o discharge Sclera - white, w/o ecthyma Cornea and lens - clear, no opacities Pupillary reaction: PERRLA, convergence intact EOM: EOMI, no nystagmus Funduscopic exam: red reflex intact BL disc margins sharp retina - no A-V nicking, hemorrhages, or exudates
Presbyopia
aging vision - progressive difficulty seeing near objects.
A-V nicking
another hypertensive change Arterial walls become thickened and lose transparency due to atherosclerotic changes. The veins appear to taper as the artery crosses. "eye is the window to the body"
Hyphema
blood in anterior chamber 2/2 trauma
Osteogensis imperfecta
blue sclera metabolic issue with Ca Ca makes sclera white Choroid is pushing through soft brittle bones (lots of breaks)
Papilledema
disc is swollen with blurred margins. Physiologic cup is not visible. Increased intracranial pressure.
Diplopia
double vision
Entropion
eyelid turns inward
Ectropion
eyelid turns outward
heterophoria
failure of the visual axes to remain parallel.
Hyperopia
farsightedness - difficulty seeing near objects.
Nystagmus
fine rhythmic oscillations of the eyes at the extreme lateral gaze.
Xanthelasma
flat yellow plaques Found under the eye. Associated with hyperlipidemias. No treatment, investigate lipids and Cholesterol.
Sty
infection at the margin of the eyelid Txt: usually abx
Conjunctivitis
infection or inflammation of the conjunctiva. Discomfort, discharge. Topical antibiotics.
Subconjunctival hemorrhage
leakage of blood under the conjunctiva. Painless, sharply demarcated, resolves on its own. Usually not associated with trauma. Stops at limbus.
Myopia
nearsightedness - difficulty seeing distant objects.
O.D.
oculus dexter (right)
O.S.
oculus sinister (left)
O.U.
oculus uterque (both eyes)
Esophoria
one eye deviates inward
Exophoria
one eye deviates outward
Fundus
optic disc and fup retina retinal vessels
Chalazion
painless nodule involving the Meibomian gland
Exopthalmos
protrusion of the eyes shouldn't see sclera above or below iris Common in hyperthyroidism (esp Graves disease)
Horner's syndrome
ptosis, miosis and anhydrosis - sympathetic innervation Miosis = excessive constriction of pupils anhydrosis - lack of sweating on one side of the face
Pinguecula
small nodule on the bulbar conjunctiva, does not cross over to the cornea.
Pterygium
thickening of the bulbar conjunctiva which grows across the cornea. (can do surgery)
Anisocoria
unequal pupils, greater than 0.5 mm difference
Ocular melanoma
unusual pigment changes on the retina
Jaundice
yellow sclera accumulation of bilirubin the sclera are more sensitive and will often turn yellow before the skin