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History and Physical Examination of the Eyes

Rizalino Jose F. Felarca, M.D. July 7, 2010


LECTURE OBJECTIVES  Includes location, severity and circumstances
surrounding onset
At the end of the lecture, the student should be able to:
C. Associated Signs and Symptoms
1. Extract an Accurate Ocular history
2. Recognize/ identify normal anatomy of the eye
3. Perform Visual Acuity exam for far and near (vision) MD: Ano pa ang nararamdaman mo?
4. Perform Digital Tonometry
5. Recognize/ differentiate normal from abnormal Px: Lumabo ho ang paningin ko…masakit na
conditions masakit ho ang ulo ko…at pulang pula daw ho
6. Identify the components of an 8 part eye exam ang aking mga mata sabi nila.

HISTORY TAKING These usually are:

 Follows the general format of history taking and 1. Redness


symptom analysis 2. Photophobia
 Can be started with an open-ended question such as 3. Discharge
“How is your vision?” of “Have you had any trouble 4. Double vision
with your eyes?”
 Pursue further details vis-avis symptom analysis if D. Consultations/ Treatment
patient verbalizes an eye/ vision problem
A. Chief Complaint MD: Nagpacheck-up ka ba sa duktor? May
gamot ka bang ipinatak o ininom?
“There is only one chief, the rest are mere Indians.”
Px: Sabi ng kapitbahay ko…baka sore eyes,
- Dave Gellogue, M.D. UERM „77
kaya nilagyan ho ng gatas ng ina. Sabi nga ng
kumare ko, ihi daw ang dapat ipatak eh.

MD: Ano po ang problema? MD: Opthalmologist ba ang kumare mo? *

Px: Doc, masakit ang aking mata?


 ask if any medications were taken or any
MD: Alin, kanan o kaliwa? consultation was sought
 * - such remarks are to be used sparingly and
with discretion, since patients react in different
B. Onset, Duration and Severity of symptoms
ways (be nice )

E. Aggravating/ Alleviating factors


MD: Kelan mo pa naramdaman ito?

Px: Mga tatlong araw na po. Px: Doc, pag umuubo o‟ umiiri ako lalaong
sumasakit, pero pag umiinom ako ng Ponstan,
MD: Paano nagsimula ito? gumagaan ng konti ang pakiramdam ko.

Px: Nagkusot ho ako ng mata…tapos


sumakit na.
F. Other pertinent questions
MD: Gaano kasakit ba ito? 1. Systemic signs and symptoms – Diabetes Mellitus,
Hypertension, cardiac disease, etc
Px: Sa sobrang sakit po, nasuka ho ako. 2. Any intake of drugs – clopidogrel or other blood
thinners, etc.
3. Prior surgery and treatment
 Characterizes the chief complaint according to
duration, frequency, intermittency and rapidity of
onset

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PHYSICAL EXAMINATION FINDINGS eyelashes against the globe,
specifically the cornea
FRESHIE FLASHBACK: 4 “actions” involved in physical IV. causes corneal irritation and
examination – Inspection, Palpation, Percussion and encourages ulceration
Auscultation (for the eyes, inspection and palpation are  Distichiasis
done)  V. Manifested by accessory eyelashes,
often growing from the orifices of the
Inspection/ “Eyeballing” (further discussed under external meibomian glands
eye exam) VI. May be congenital or the result of
 This presumes that you have done history taking on inflammatory metaplastic changes
your patient. a. Lids
 LOOK at the lashes, lids, and palpebral openings and o Note position in relation to eyeballs as well
note for abnormalities as color of the skin
o Inspect for presence of edema and lesions
The 8-part Eye Exam NORMAL  Are modified folds of skin that can close to
I. Visual acuity protect the anterior eyeball
Each eye is evaluated by itself, since binocular testing will not
reveal poor vision in one eyes  The upper eyelid ends at the eyebrows
and the lower lid merges into the cheels
a. Snellen Test
- uses a chart with different sizes of letters or forms SIGNIFICANT  ECTROPION
- shows how accurately you can see from a distance FINDINGS VII. Sagging and eversion of the lower
- It is viewed at 6 metres (20 feet). A visual acuity of lid
6/6 indicates that the chart was viewed at 6 metres, VIII. Usually bilateral and frequently
and the lowest line that could be read was labelled 6. found in the elderly
- Illiterate „E‟ chart: Utilizes tumbling "E" letter for IX. May be iatrogenic (E.g. From
illiterate patients and for children. improperly sutured laceration)
 ENTROPION
b. Jaeger eye chart - Turning inward of the lid
- For reading up close and determining near vision - May be a result of aging
- As you progress to larger lettered paragraphs, the (involutional), conjunctival and
lettering size increases for lesser visual acuity. tarsal scar formation (cicatricial), or
congenital
Note: Uncorrected VA is measured w/o glasses or contact  External Hordeolum
lenses. Corrected acuity means these aids were worn. - An infection of the glands of the
eyelids, usually due to staph
c. Pinhole test - Involves the Zeis‟s or Moll‟s glands
- Viewing the Snellen chart through a placard of - Internal hordeolum: involves the
multiple tiny pinhole – sized openings Meibomian glands
- prevents most of the misfocused rays from entering  Chalazion
the eye. - chronic granulomatous
inflammation of the Meibomian
II. External eye exam glands
a. Position and alignment of the eyes - characterized by painless localized
o Stand in front of the patient swelling
o Survey the eyes for position and alignment - lacks the acure inflammatory signs
o Note the presence of protrusion as in Graves‟ of hordeolums
disease (see section on Proptosis)  Graves’ Disease
b. Eyebrows - Lid retraction is a pathognomonic
o Inspect and note quantity and distribution symptom of thyroid disease,
o Also note scaliness or any changes in the associated with exopththalmos
underlying skin - Accompanied by hypertrophy of
c. Lashes recti muscles
NORMAL  Eyelashes project from the margins of the - causes puffiness of the lids
eyelids and are arranged irregularly. - controlled with meds
 Upper lashes – more numerous and turn a. Palpebral Fissure
upward o Reflects the adequacy with which the
 Lower lashes – turn downward lids close
SIGNIFICANT  Trichiasis o Especially notable in conditions were the
III. inversion and rubbing of the eyes are unusually prominent, when

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there is facial paralysis, or when the a. Direct response to light
patient is unconscious - refers to constriction of the illuminated pupil
- reaction may be graded as brisk or sluggish
NORMAL  The elliptic space between the two open - To avoid accommodation, the patient is asked to
lids stare in the distance as a penlight is directed toward
 Terminates at the medial and lateral each eye.
canthi (the angle at either end of the - Normally a consensual contriction will simultaneously
eyelid) occur in the opposite nonilluminated pupil. This is
SIGNIFICANT  Down Syndrome – upstarting palpebral usually a slightly weaker response.
FINDINGS fissures
b. Swinging Penlight Test for Marcus Gunn Pupil
NOTE: Based on Bates, the lashes and palpebral fissures are - As a light is swung back and forth in front of the two
included under the examination of eyelids. This trans follows pupils, one can compare the direct and consensual
the format presented to the class, so please be guided reactions of each pupil.
accordingly.  - Since the direct reaction is usually stronger than the
consensual, each pupil should immediately constrict
b. Proptosis slightly more as the light falls directly on it.
o Displacement of the eyeball forward due
to any increase in the orbital contents IV. Motility exam
o Hallmark of orbital disease Objective: evaluate the alignment of the eyes and their
o Not in itself injurious unless the lids are movements both individually (ductions) and in tandem
unable to cover the cornea (versions).
o E.g. Graves‟ disease – accompanied by
lid retraction a. Testing Alignment
- Simple test of binocular alignment: performed
NOTE: The following were not lectured to us but is part of the by having the patient look toward a penlight
eye exam, according to Bates… held several feet away. A pinpoint light
reflection or reflex should appear on each
c. Lacrimal Apparatus cornea and should be centered over each pupil
o Inspect the regions of the lacrimal gland if the two eyes are straight in their alignment.
and sac - Cover test: Patient is asked to gaze at a distant
o Note the presence of swelling target with both eyes open. If both eyes are
fixating together on the target, covering one
d. Conjunctiva and Sclera eye should not affect the position or continued
o Ask the patient to look up as you depress fixation of the other eye. To perform the test,
the lower lid with your thumb the examiner suddenly covers one eye and
o For a fuller view, spread the lids with carefully watches to see that the second eye
your thumb and finger then ask the does not move (indicating that it was fixating
patient to look to each side and down on the same target already).
o Inspect the color and vascular pattern
o Look for nodules or swelling b. Testing Extraocular Movements
- The patient is asked to follow a target with
e. Cornea and Lens both eyes as it is moved in each of the four
o Use oblique lighting cardinal directions of gaze.
o Inspect for any opacities (e.g. cataract) - note the speed, smoothness, range and
symmetry of movements and observes for
f. Iris unsteadiness of fixation (eg. Nystagmus)
o While inspecting the cornea and lens,
inspect the iris V. Tonometry
o Markings should be clearly defined - Measurement of intraocular pressure (IOP)
o With the light shining directly from the - Measured in mmHg
temporal side, look for a crescentic - normal IOP is around 10-21mmHg
shadow on the medial side of the iris (in - High IOP may indicate glaucoma or ocular
a normal iris, this is not seen since it is hypertension
fairly flat) - Low IOP may indicate ocular hypotension
observed in conditions like retinal detachment
III. Pupillary exam and iritis
 Basic exam: pupils = symmetric and reacts to both
light and accommodation a. Digital Tonometry
 Normal pupil size: 3-4 mm - use of the examiner‟s fingertips to estimate the IOP

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- may be used with uncooperative patients or when - abnormal field can indicate a problem in the retina,
there is no instrument available optic nerve, or visual pathway

Procedure: Performing confrontational field test:


1. Ask the patient to look down (patient‟s eye must not
be closed) while the examiner‟s forefingers (usually a. Screening – starts in the temporal fields (most
the index and middle finger) gently rests on the defects include these areas)
superior aspect of the eye.
2. The other fingers may gently rest on the patient‟s 1. Imagine the patient‟s visual fields projected onto
forehead. a glass bowl that encircles the front of the
3. The examiner gently and alternately depresses both patient‟s head
forefingers on the globe while assessing the tone. 2. Ask the patient to look with both eyes into your
Normotensive eye (normal IOP): similar tone to the eyes
tip of the nose 3. While you return the patient‟s gaze, place your
Increase IOP: tone of glabella hands 2 feet apart, lateral to the patient‟s ears
Decrease IOP: tone of the lips 4. Instruct the patient to point to your fingers as
4. Repeat the same procedure with the other eye. soon as they are seen
5. Slowly move the wiggling fingers along the
imaginary bowl and toward the line of gaze until
the patient identifies them
6. Repeat this pattern in the upper and lower
quadrants

When the patient sees both sets of fingers at the


same time, the fields are normal.

b. Further Testing – when a defect is detected; one


eye at a time is tested.

1. When testing for the eye with a suspected


temporal defect: ask the patient to look into your
b. Goldmann Applation Tonometry
eye directly opposite to that of with defect while
- Instrument: goldman applation tonometer attached to
the normal eye is covered (e.g. a patient
the slitlamp
suspected with left temporal defect covers her
- Measures the amount of force required to flatten the
right eye while the left eye looks directly to your
corneal apex by a standard amount
right eye).
o The higher the intraocular pressure, the
2. Slowly, move your wriggling fingers from the
greater force required
defective area toward the better vision, noting
where the patient first responds.
- More accurate than Schiotz tonometry
3. Temporal defect suggests nasal defect on the
opposite eye. Examine the opposite eye similarly
moving from the anticipated defect toward the
c. Schiotz Indentation Tonometry
better vision.
- Advantage: simple, inexpensive, easily portable
handheld instrument
- Disadvantage: requires greater expertise

Note: since both Goldman applation tonometry and Schiotz


tonometry uses devices that touch the cornea, they require
local anesthetic and disinfection of the instrument tip prior to
use.

VI. Confrontation tests

Visual field Visual field defects


- portion of a subject‟s surroundings that is visible at
any one time
- measures sensitivity: ability to detect light thresholds
at different locations

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VII. Slit lamp Biomicroscopy
Tenks poWz sa mga sumusunod: Boss Bob: for trying to
procure the ppt for us, salamuch for your hard work
Slit lamp Biomicroscope preZ, Marco: thanks for the ppt pics, without which this
- Is a unique instrument that permits trans may not have existed…
magnified examination of transparent or
translucent tissues of the eye in cross- Pabati naman kina…
Kimmy-dora, Ricky, “schwing”, Boss A, Friend, Jayms,
section. Partner, Ue-Rm: kilala niyo naman kung sino kayo (lalo
- Enhances the external examination by na yung huli), thanks for the laugh trips and the lunch
allowing a binocular, stereoscopic view, a “parties” XD
wide range of magnification, and Mariel andAboy: ayan ha, pilit na pilit! Good luck sa
boards! Wag sana tumaas PF niyo kahit may license na…
illumination of variable shapes and To my prospective seeses: ano kayo cohort?
intensities to highlight different aspects of Haha..tandaan, walang bibitiw!
ocular tissue. Transmates: beh, buddypoke and tol: salamuch sa
- Is indispensible for the detailed examination inyong hardwork! Let’s give each other a pat on the
back…*aray*…wag naman ganyan kalakas…(
of virtually all tissues of the eye.
Bully: habang ginagawa ko ang shoutout na ‘to naamoy
- It is routinely used for examination of the ko na birthday mo…sige na nga…Merry Christmas! ‘Wag
anterior segment, which includes the ka na manulak sa stairs ha, may elevator shaft naman
anterior vitreous and those structures eh…
anterior to it.
God bless sa exams batchmates!!! Go lang ng Go!

VIII. Opthalmoscopy --Cooks to go--

OPTHALMOSCOPY / FUNDUSCOPY Hi sa mga taga bahay ni kuya!!! 


- Is the examination of the posterior segment Hi groupmates!!! 
of the eye, performed with an instrument Hi transmates!!! Yey, 1st trans ko to. Hehehe 
called the opthalmoscope.
WAG KANG MANLALANDI KUNG HINDI MO MAHAL AT
2 Types of Opthalmoscopy WAG KANG MAGPAPALANDI KUNG ALAM MONG
a) Direct Opthalmoscopy MASASAKTAN KA LANG. – isang ate sa jeep.
 Allows one to focus on the retina
itself
OVERHEARD OUTSIDE UE:
 Hand-held direct opthalmoscope Hello Ger? Asa na ka? Pasundo n ko diri sa UE..Ha? Naa
provides a monocular image of the pa ka sa balay? Diri dong sa UE, sa atubangan ha? Sa
ocular media and fundus magnified may waiting shed.. Cge.. 
15 times normal.
(thanks nikki for translating)

b) Indirect Opthalmoscopy
 So called because one is viewing an
“image” of the retina formed by a
hand-held “condensing lens”.
 Provides a much wider field of view
with less overall magnification
(approximately 3.5x using a
standard 20-diopter hand-held
condensing lens).

NOTE: Please refer to the powerpoint for the pics. Let‟s save
ink and paper! (mahal ang libro eh )

-----------------------------------FIN-------------------------------------
REFERENCES:
Bates‟ Guide to Physical Examination
Vaughan & Asbury‟s General Ophthalmology
8 Part eye exam handout
Lecture PPT

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