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