3/23/2013

Optical Coherence Tomography (OCT) OCT : retinal layers

Central vs Peripheral vision Extraocular muscles

RPE

E
Outer Layer

Peripheral Vision: Central Vision:

Rods (95 million) Cones (5 million)
30% Ganglion cells 70% Ganglion cells

Low resolution High resolution

Scotopic Photopic / color
P:G ratio 1000:1 1:1
Horizontal Vertical
Photoreceptors
Cones, Rods • Medial and lateral recti • Superior and inferior recti
Inner Nuclear • Superior and inferior obliques
visual fields Visual acuity, color Ganglion cells

History History: Temporal course

• How the eye feels , sees , or looks 20/20
Tumor, Cataracts,
• e.g. . . . . . Pain, Blur, Redness Glaucoma, Diabetes, Optic neuritis
ARMD
Uveitis
• Location, quality, severity, chronology, timing, duration,
Visual Acuity

Vitreous hemorrhage
association, modifies
• Common symptoms:
Vision loss photophobia
visual distortion night blindness
eye pain color loss AION, CRAO, ARMD
diplopia tearing Retinal Detachment

transient vision loss redness 20/200

irritation floaters
photopsia discharge
min - days weeks months
hrs

2
 3/23/2013

Visual Acuity Visual Acuity

• IMPORTANT
• Best corrected vision (with glasses or pinhole)
• Test at distance (20 ft) if possible
• At near, consider presbyopia (>45)
• Coax the patient !
– Guessing is permitted and should be encouraged.
20 = distance to chart 10 = 20
20 = letter size 20 40
(5’ arc at 20 feet)

Pupil Examination
• Light Reflex
– Subject must fixate at distance
– Symmetry, latency and velocity of constriction
Pupil • Near Response
– Convergence, accomodation and miosis
• Consensual Response

Afferent Pupillary Defect

(=APD, Marcus Gunn Pupil, Swinging Flashlight Sign)

• IMPORTANT !!
• Paradoxical mydriasis to
Inspection
swinging flashlight Adnexa
• Sign of assymetric optic
nerve or retinal dysfunction
Anterior Segment
• Reliable and objective Alignment
evidence of organic disease.

3
 3/23/2013

Eyelid Anterior Segment

Conjunctiva

Cornea

Anterior
chamber

Anterior Segment Motility

Iris

• Ductions vs Versions (gaze)

Lens • Alignment of both eyes in primary position
• Alignment in eccentric gaze

Corneal reflex can be used to assess Assesment of Alignment

both Alignment and Ductions (Hirschberg)
Ortho Exo

30o
10mm
Eso
20o

1mm = 15 10o

2mm = 30
4 mm = 45
limbus = 60 

4
 3/23/2013

Assessment of Ductions and Versions DIPLOPIA

30o Binocular
Monocular
30o 30o
• Diplopia that persists with • Diplopia is only present
monocular occlusion with binocular vision
• Resolves when either eye
10 mm 10 mm
occluded.
10 mm
• Non paralytic strabismus
30 0 30 0 • CNS
• Cranial nerve: III, IV,VI
10mm OD 30 0 OS 10mm • Neuromuscular junction
• Extraocular muscle

10mm 10mm

Oculomotor nerve palsy Abducens nerve palsy

Pupillary Dilation
• Document best corrected acuity

• Document pupil exam

• Obtain consent from the patient

• r/o allergies

• r/o impending neurological

catastrophe (herniation)
Fundus
• Check for shallow chamber

• 2.5% neosynephrine

29

5
 3/23/2013

Normal Fundus Normal Fundus

a

v
f

D c
M

Optic disc Optic disc edema v papilledema

C/D = < .1 C/D = .3

Normal Normal

normal Optic disc edema

C/D = .8
Glaucomatous
Optic
optic atrophy atrophy

Hard and Soft Exudates Basic Eye Examination: Part B

Patrick Sibony, MD
Updated October 17, 2011, Mar 15, 2013

6
 3/23/2013

Eye Examination : components

• Visual acuity
• Color
• Inspection (in order)
• adnexae, anterior segment.
• alignment and eye movements
Visual Fields
• Pupils: light reflex and APD .
• Fundus
• Visual fields.
• Tonometry when indicated.

Visual Field Basics Visual Field Techniques

• Monocular testing Size and
brightness

• Monitored fixation on central

target.
• Subjective response to
stimulus that varies in size,
brightness and location
• Static Perimetry
• Kinetic Perimetry
Static Perimetry Kinetic Perimetry
• Confrontation visual fields

Localization of the Visual Field

Visual Field Conventions

• Visual Fields test central and peripheral vision

• Anatomic vs Visual Field (as the patient sees)

Optic nerve

Chiasm
• Upper VF projects onto inferior hemiretina;
lower VF projects onto upper hemiretina
Optic tract/geniculate

• Nasal VF projects onto temporal hemiretina;

Visual Radiations Temporal VF projects onto nasal hemiretina

7
 3/23/2013

Prechiasmal NFBL* Visual Field Defects Chiasmal Visual Fields

• Monocular • Binocular
• Horizontal
• Papillomacular
• (abnl VA, Color) • Assymetric
• (abnl APD)
• (+ disc) Arcuate scotoma Central scotoma • Respects the vertical

• Bitemporal defect

* Nerve fiber bundle layers

Altitudinal defect Step defect

Bitemporal Hemianopsia Chiasmal Visual Fields

80 % of chiasmal optic neuropathies
are due to tumors
• Pituitary adenoma
• Meningioma
• Craniopharyngioma
• Glioma, aneurysms, inflammatory

Chiasmal Visual Fields Chiasmal Visual Fields

8
 3/23/2013

Retrochiasmal Visual Fields Homonymous Hemianopsias

• Binocular Complete
• Homonymous

• Respect for vertical Incongruent

meridian

• Optic tract; temporal ,

parietal or occipital lobes.
Congruent

Localization along the Visual Radiations

Parietal Lobe Temporal Lobe

Occipital Lobe

9
 3/23/2013

Case EB.27yoWF
History • PMH:

– none
• Woke up with a “smudge” in

CASES her vision OD – last year : numbness and

paresthesias, right thigh
• Over the last 3 days, smudge 3weeks and then
has become more opaque; resolved. Evaluation by
located dead center. PMD was unrevealing.
• Meds: none
• Colors seem washed out,
• Allergies: none
vision seems darker in that
eye
• Painful , especially when she
moves her eyes.

Case EB.27yoWF Case EB.27yoWF

• Examination.
– Visual acuity: 20/60 OD; 20/20+ OS
– Color: 2/8 OD, 8/8 OS
– Pupils: APD OD
– Anterior segment : normal
– Eye movements: normal
– Fundus: photo
– Visual fields: photo.

Case EB.27yoWF MRI

• Where is the lesion ?
– Acuity, APD, color, the absence of any retinal
disturbance and the VF defect
• What is the lesion ?
– Consider age, mode of onset, associated
symptoms and medical problems,
• Diagnosis ?

10
 3/23/2013

Case JK.32yoWF Case JK.32yoWF

History • PMH:

– none • Examination.
• 6 m history of progressive
decline in vision OD>OS. – Amenorrhea x 1yr – Visual acuity: 20/100 OD; 20/40 OS
• Headaches
• ROS: negative – Color: 4/8 OD, 6/8 OS
• Meds: none
• Recent onset of lactation
– Pupils: Light reflex normal; APD OD
• Allergies: none
(galactorrhea) – Anterior segment : normal
– Eye movements: normal
– Fundus: photo
– Visual fields: photo.

Case JK.32yoWF Case JK.32yoWF

OD OS
• Where is the lesion ?
– Acuity, APD, color, binocularity , the absence
of any retinal disturbance and the VF defect
• What is the lesion ?
– Consider age, mode of onset and progression,
associated symptoms and medical problems,
• Diagnosis ?

OS OD

Case JK.32yoWF Summary Slide

• Vision
• Inspection
(Adnexae, Anterior segment, Alignment )
Pituitary Adenoma:
Prolactinoma • Pupillary Defect (APD)
• [Extra: Versions, Fundus, VF]

11
 3/23/2013

More Pupil

Anisocoria Pharmacologic Iris

• Physiologic anisocoria
– 20 – 40% of normals, < 2mm assymetry
– Both pupils react normally, no ptosis or diplopia Adie’s Tonic Pupil
• Efferent lesion:
– Parasympathetic (constrictor):
• worse in light
– Sympathetic (dilator):
• worse in dark IIIrd nerve palsy

• Afferent lesions do not cause anisocoria

Oculosympathetic Pathways Horner’s Syndrome

Light
3o
Dark
1o
2o
Cocaine
10%

12