OBJECTIVE - SUBJECTIVE EYE

EXAMINATION-REFERRAL SYSTEM
AND WHEN TO REFER

dr.Michael Indra Lesmana,Sp.M

Faculty of Medicine UKRIDA
SUBJECTIVE EXAMINATION
• Disturbance in vision
• Ocular discomfort
• Abnormal ocular appearnace
• Abnormal ocular secretions
 Time & manner of onset
• Chronic visual loss
• Acute visual loss
 UNILATERALITY &
BILATERALITY
Unilateral - e.g. trauma, vascular occlusion,
secondary glaucoma

Bilateral- e.g. cataracts, age related macular

degeneration (ARMD), diabetic retinopathy
 SYMPTOMS
• Disturbance of vision
– Blurring of central vision
– Decreased peripheral vision
– Altered image size/shape
– Diplopia
– Flashes and floaters
– Iridescent vision
– Color vision problems
– Dark adaptation problems
• Ocular pain or discomfort
– Foreign body sensation
– Photophobia
– Ciliary pain
– Itching
– asthenopia
• ABNORMAL SECRETIONS
– Lacrimation/epiphora
– Discharge
– Dryness
 ABNORMAL SIGNS
• Ptosis- drooping of the upper eyelid
• Proptosis- outward protrusion of an eyeball
• Enophthalmos- a “ sunken “ eyeball
• Blepharitis- infection of lid margin
• Strabismus- deviation of one or both eyes
• Redness – extreme vascularity of
conjunctiva
• Opacity- disturbance of clarity
• Masses- tumor lesions
 Objective examination
• Visual acuity
• External eye examination
• Anterior segment examination
• Pupils
• Ophthalmoscopy
• Occular motility
• Tonometry
• Visual field examination
 Visual acuity
• Uncorrected distance
• Corrected distance
• Pinhole test
• Near vision test
Snellen’s Chart
Jaeger Chart
 External eye examination
• Ocular adnexae
• Orbit
• Conjunctiva
External Eye
Blepharitis
Entropion
Ectropion
Membranous Conjunctivitis
Follicular Hypertrophy
Papillary Reaction
Lid mass
ptosis
Lid Eversion
 Anterior segment examination
• Cornea
• Ant. Chamber
• lens
Corneal Abrasion
Slit Lamp Examination
 PUPILS
• Direct reflex
• Consensual reflex
• Normal pupil size 3-4mm under normal
illumination
 OPHTHALMOSCOPY
• Direct ophthalmoscopy
– Small field of view
– Upright image
– A large image size
– No stereopsis
• Indirect ophthalmoscopy
– Large field of view
– Inverted image
– Small image size
– Stereopsis( depth perception of 3-
dimensionality)
 OPHTHALMOSCOPY
• STRUCTURES
– Optic nerve head- CD ratio of less than 0.3mm
– Vessel caliber- AV ratio 2:3
– Retina
– Macula
 OCCULAR MOTILITY
• 6 Cardinal Positions of Gazes
• Lateral rectus – (CN VI)
• Sup. Oblique- ( CN IV)
• the rest of the EOMs are innervated by CN
III
Strabismus
 TONOMETRY

• Normal IOP 10-22mmhg

• Applanation tonometry
• Schiotz tonometry
 VISUAL FIELD
EXAMINATION
• Confrontation test
• Automated perimetry e.g. Octopus,
Humphrey
 When to refer?
• Decreased of visual acuity with or without
eye redness and pain
• No improvement inspite of medical
treatment
• Medical competency (know the limitation)
 Eye Emergency-BPJS
• Corneal Foreign body
• Blenorrhoe
• Acute dacryosytitis
• Endophthalmitis/panophthalmitis
• Acute Angle closure Glaucoma
• Sudden B.O.V (Retinal detachment, CRAO,
Vitreous haemorrhage)
 Eye Emergency-BPJS
• Orbital cellulitis
• Any Corneal abnormality (erosion/ulcer)
• Ocular trauma
• Orbital tumour with bleeding
• Uveitis
 Referral system
• Clinic-type C-B-A Hospital/ Public
Hospital
• Make a proper referral letter and give initial
treatment and have a good communication
• Refer to have ancillary test (USG,
perimetry, OCT, Biometry)
 BPJS-Eye diseases
1. Cataract
Indication of Phaco surgery is Visual acuity
is less than 6/18, at least one month interval
for the fellow eye.
2. Pterygium
Indication of Pterygiumplasty if Grade III-
IV
 BPJS-Eye diseases
3. Diabetic Macula edema
Bevacizumab is off label drug, and has
been excluded as a drug covered by BPJS
4. Retinal detachment
should be referred to B/A type Hospital
THANK YOU