1. Good afternoon, Doctors.

I am Marianne Lorenzo, a post-graduate intern and I’ll be reporting on the History and Physical
Examination of the Eye.

2. This are my objectives

3. This is the outline of my presentation

CHIEF COMPLAINT
 reason for consult
 The patient's main complaint should be recorded in the patient’s own words or in a nontechnical paraphrasing of the
patient’s word.
 It’s not advisable to draw hasty conclusions by employing medical terms that suggest premature diagnosis.
 For example, chief complaints should be listed as redness, burning, mattering or light flashes instead of conjunctivitis.

1. What are the main problems that you are having with your eyes?
2. What other problems are you having with your eyes?
3. Why did you come (or why were you sent) here?
4. What is it about your eyes that worries or concerns you?

PRESENT ILLNESS
This is grouped into: abnormalities of vision, ocular appearance and sensation

For the abnormalities of vision, we have vision loss and visual abberations
Patients can describe visual loss as “nanlalabo”, “maulap ang panningin”, “nawawala ang
paningin” or “nabulag”

For the visual abberations:

GLARE OR PHOTOPHOBIA
Patients may describe this as “silaw” or “nasisilaw”
(+) pain – photophobia; (-) pain – glare

VISUAL DISTORTION
Manifests as irregular patterns of dimness, wavy or jagged lines, image magnification/ minification. May be caused by migraine,
optical distortion from strong corrective lenses, lesions involving the macula and optic nerve.

FLASHING/FLICKERING LIGHTS
Patients may describe this as “may parang kidlat”, “biglang may maliwanag”
May indicate retinal traction, or migrainous scintillations.

FLOATING SPOTS
“May lumulutang sa harap ng mata”
May represent normal vitreous strands due to “normal” vitreous changes.Or may be secondary to pathologic presence of
pigments, blood, or inflammatory cells.
Syneresis – vitreous aging process (60 y/o and above) (As one ages, the vitreous undergoes "syneresis," in which it becomes
more fluid or liquid-like.)

OSCILLOPSIA
“Gumagalaw o lumilikot and paningin”
Shaking field of vision may be due to harmless lid twitching (myokymia), or to certain forms of nystagmus

DOUBLE VISION
“Nagdadalawa ang paningin” “doble ang paningin” “naduling”
Monocular diplopia manifest as split shadow or ghost image – do not disappear when one eye is covered. Causes include
uncorrected error of refraction, media abnormalities such as cataract, corneal irregularities
 Binocular diplopia disappear when one eye is covered. One cause is a paralysis of ocular muscle.

For the abnormalities of ocular appearance, red eye, ptosis, focal growth, exophthalmos, ocular deviation/misallignment
RED EYE
Must differentiate between redness of the eyelid and periocular area from that of the globe
 “Namamaga ang mata” (preseptal cellulitis/orbital cellulitis) VS “Namumula ang mata” “sore eyes” (conjunctivitis)
VS “Dumudugo ang mata” (subconjunctival hemorrhage)

Color abnormalities other than redness : Jaundice and Hyperpigmented spots seen in wilson’s dse
PTOSIS
“Napipikit”, “kirat ang mata”
Ptosis is a drooping or falling of the upper eyelid. The drooping may be worse after being awake longer when the individual's
muscles are tired.

FOCAL GROWTH – in the eyelids or eye surface , “bukol”, “maga”

EXOPHTHALMOS – protrusion of the eyeball, “lumuluwa ang mata”

Ocular deviation or misalignlent – “duling”, “banlag” ;

 esodeviation (inward turning of the eye),
 exodeviation (outward turning of the eye),
 hypertropia (upward turning of the eye) or
 Hypotropia (downward turning of the eye)

For the abnormalities in ocular sensation: Eye pain, irritation and headache
EYE PAIN
“masakit” “makirot” “mahapdi”
Must be characterized in terms of location:
 Periocular (maybe tenderness of the lid, tear sac, sinuses or temporal artery)
 Retrobulbar (due to orbital inflammation, orbital myositis, optic neuritis) – inside the eyes; d/t inflammation of iris and
ciliary body
 Ocular (may be due to a corneal abrasion, corneal foreign body glaucoma, endophthalmitis)
 No specific (fatigue from ocular accommodation binocular fusion)

EYE IRRITATION
Superficial discomfort is usually caused by ocular surface abnormalities.
 Itching – often a sign of allergic sensitivity, “makati”
 Dryness – burning, gritty, mild foreign body sensation. Can occur with dry eyes or other types of mild corneal irritation
“may buhangin”, “maaligasgas”
 Tearing – may be due to irritation of the ocular surface or maybe a sign of abnormal lacrimal drainage, “nagluluha”
 Ocular Secretions – “nagmumuta”, Characretize discharge as to color, consistency, amount
a Mucoid discharge – allergic
b Mucopurulent – bacterial/viral conjunctivitis
c Dried matter/crusts on lashes – Blepharitis

HEADACHE
Uncorrected errors of refraction and presbyopia frequently cause headache referred to the eyes or brow and comes with
reading and computer work.
Migraine headaches and sinusitis are frequent causes of headache.
Headaches may not come from the eye. High and low blood pressure may also give rise to headaches around the eyes.
Headache from rise in intracranial pressure is usually severe and associated with nausea and vomiting.

***This symptoms should always be described according to: ONSET, DURATION, FREQUENCY, DEGREE, and LOCATION

For the PAST OCULAR HISTORY, ask for

Existence of any eye problem
Uses of glasses or contact lenses
Uses of ocular medications in the past
Ocular surgery (including laser, cataract surgery)
Ocular trauma
History of amblyopia (lazy eye) or of ocular patching in childhood

For the OCULAR MEDICATIONS

All current and prior ocular medications used for the present illness should be recorded, including dosage, frequency, and
duration of use.
Ask about the use of any over the counter (nonprescription) medications and home remedies.
Knowledge of the patient’s use of ocular medication is for us to
 To know how the patient responded to prior therapy
 Recent therapy can affect the patient’s present status

GENERAL MEDICAL AND SURGICAL HISTORY

Many ocular dses are manifestation of or associated with systemic dses
General medical status must be known to perform a proper pre-op evaluation

SYSTEMIC MEDICATIONS
Can cause ocular pre-operative, intraoperative and post-operative problems
Provide clues to systemic disorders the patient might have
Give particular attention to the use of Aspirin and other blood-thinners as they can cause intraoperative and post-operative
bleeding
Tamsulosin, an α1-adrenoceptors antagonist used in BPH can cause floppy iris syndrome.
Hence, these medications must be hold for atleast 5 days before surgery

ALLERGIES
Allergies to medications and environmental agents must be asked
 Itching
 Hives
 Rashes
 Wheezing
 Frank cardiopulmonary collapse

SOCIAL HISTORY
Smoking, Alcohol use - ARMD
Drug abuse - retinopathy
Sexual hx (STD, HIV)
Presence of pets (dogs, cats) - toxoplasmosis, toxocara

FAMILY HISTORY
Family hx of ocular and non-ocular disease is important when genetically transmitted disorders are under consideration

EYE EXAMINATION
Notations

DISTANCE VISUAL ACUITY

Distance visual acuity measurement should be performed in all patients, including children because of the importance of early
detection of amblyopia.
Determination of visual acuity is done prior to any manipulation of the eye to avoid any medico-legal
issues that may arise in the future.
Distance visual acuity is recorded as a ratio or fraction which compares the performance of the patient with an agreed upon
standard.

Visual acuity of 20/20 represents normal vision.

In performing a distance Visual Acuity,

1. Place patient at the designated distance of 20 feet or 6 meters from a well illuminated Snellen Chart. If the patient has
corrective lenses, ask the patient to wear them during the test.
2. By convention, the right eye is tested and recorded first. Have the patient occlude his left eye using an opaque occluder. The
palm of the patient’s hand may also be used to occlude the vision in the right eye.
3. Ask the patient to read the chart starting at the 20/200 line proceeding to the smallest line which he/she can distinguish
more than half of the letters.
4. Record the acuity measurement by jotting down the numeric designation of the smallest line that the patient was able to
read.
5. Occlude the patient’s right eye and repeat steps 3 and 4.
6. If the patient’s visual acuity is less than 20/20 in one or both eyes, repeat the test with the patient viewing the test chart
through a pinhole occluder and record these results. (Improvement of the patient's vision using pinhole would imply that the
patient probably has error of refraction )
If the patient cannot see the largest Snellen letter:
1. Reduce the distance between the patient and the chart until he/she is able to read the 20/200 line. Record this new distance
as the numerator of the acuity designation while retaining the denominator. For example, if the patient is able to read the
20/200 line at a distance of 10 ft, the vision is recorded as 10/200

2. If the patient is unable to see the largest Snellen letter even at a distance of one meter or 3 feet, hold up one hand and ask
the patient to count the number of extended fingers. Record the distance at which counting fingers is done accurately. For
example, if a patient can count fingers at a distance of 2ft, VA is recorded as CF at 2ft

3. If the patient cannot count fingers, determine whether or not he/she can detect the movement of your hand. Record a
positive response as hand motion designated as HM.

4. If the patient can detect hand motion, use a penlight to determine if the direction of the source of the light can be correctly
detected by the patient. Shine the light on four quadrants
good LPj able to identify light source in all four quadrants
fair LPj able to identify light source from 2-3 quadrants
poor LPj able to identify light source only from one quadrant

5. If the patient is unable to correctly identify the direction of the source of the light but is able to detect its presence, record
the patient’s response as light perception (LP).

6. If the presence of light can not be detected by the patient, this is recorded as No Light Perception (NLP)

In some instances, as in infants or toddlers, one will not be able to utilize these standard charts in determining visual acuity. In
such instances, the examiner should be alert to other signs. Withdrawal or a change in facial expression in response to light or
sudden movement indicates the presence of vision.

NEAR VISUAL ACUITY

Near visual acuity testing is routinely done for patients over 35 years of age.
Otherwise, testing “at near” is done if the patient complaints about their near vision.
It is also sometimes done for instances when distance testing is difficult or impossible (at patient’s bedside).
Unlike distance vision testing, near vision is tested with both eyes open.
The standard near vision chart is held at a distance of 14 inches or 35 cm. If the patient normally wears glasses for reading, he
should wear them during testing.
Since letter size designations and test distances vary, both size and distance should be recorded (ex. J5 at 14 inches, 6 pt at 35
cm).
If a standard near vision card is not available, any printed material such as a telephone book or a newspaper may be
substituted.
Both the approximate type size read and the distance at which the material was held are recorded.

CONFRONTATION TESTING
patient is seated facing the examiner with one eye covered while the examiner closes the opposite eye
examiner briefly shows a number of fingers of one hand (usually one, two, or four fingers) peripherally in each of the four
quadrants
patient must identify the number of fingers flashed while maintaining straight-ahead fixation
upper and lower temporal and the upper and lower nasal quadrants are all tested in this fashion for each eye

GROSS EXAMINATION
With adequate illumination, the examiner can inspect the lids, surrounding tissues and palpebral fissure. The presence of
redness or any mass should be noted and recorded.
Palpation of the orbital rim and lids may also be indicated based on the patient’s history and symptoms.
The position of the eyes should be examined from in front, from above, (looking down over the patients brow while seated),
and from the side. These views would highlight any possible protrusion of the eye ball.

With the aid of a penlight, inspection of the conjunctiva and sclera is done to note the presence of any abnormality. Instruct the
patient to look up while retracting the lower lid or look down while raising the upper lid to note the presence of redness,
discharge or any other abnormalities.
The penlight also aids in the inspection of both the cornea and the iris.

Direct Pupillary Reaction. To test the pupillary reaction to light, first direct the penlight at the patient’s right eye and note if it
constricts.
Constriction is a normal reaction. Repeat the procedure on the left eye to test the left pupil.
Consensual Pupillary Reaction. To test the consensual pupillary reaction to light, direct the penlight at the right eye and watch
the left pupil to see if it constricts along with the right pupil. The presence of constriction is the normal consensual response.
Repeat the procedure for the left pupil, watching the right pupil for the response.

Frequently, pupillary inspection reveals active or prior eye disease with alterations in pupillary shape or size due to damage to
the pupillary sphincter or adhesions between the iris and the lens.

OCULAR MOTILITY TESTING

Examining the eye movement begin by observing the eyes in the primary position (I.e. looking straight ahead)
With both eyes open instruct the patient to follow your finger or a small target through the six cardinal position of gaze.
Observe they eye if there is any limitation of movement.
When the EOM movement is tested with both eyes open, this is referred to as Version Test.
Repeat the same examination one eye at a time - Duction Test.
A nerve palsy or muscle weakness can alter the movements of the eyes when going through the six cardinal positions

INTRAOCULAR PRESSURE
The average IOP in a “normal” population is 15 mm Hg, however IOPs in the range of 10 to 21 mm Hg are still considered to be
within the normal range.

Intraocular pressure is measured by tonometry.

Goldman tonometry is most commonly used and is considered the “gold standard.

In the absence of any instrument, however, IOP can be estimated by palpation. This is done by carefully applying pressure using
your forefingers on the upper lid while the patient is looking down. Palpating a “soft” eye would be the same as palpating the
tip of the nose. An eye perceived to be softer than these is considered to be “hypotonic”. If the eye is palpated to be hard on
palpation, this is reported as “firm” and the patient is suspected to have an elevated IOP.

FUNDUS EXAMINATION
The fundus can be examined by direct ophthalmoscopy using an ophthalmoscope, or by indirect (often binocular) methods such
as an indirect ophtalmoscope

Direct Ophthalmoscopy
Check the light source
Adjust the light to the largest circle. Adjust lens setting to zero
The room should be dim, px comfortably seated
RIGHT EYE of px = hold ophthalmoscope with RIGHT HAND, use examiner’s RIGHT EYE
LEFT EYE of px = hold ophthalmoscope with LEFT HAND, use examiner’s LEFT EYE
Look straight at the pupil red reflex
Slowly come closer to the px at an angle 15 degrees temporal to the px’s line of sight.
When the retinal vessel comes into view follow it as it widens to the optic disc which lie nasal to the center of the retina
Examine the optic disc, retinal blood vessels, retinal background and macula

INDIRECT OPHTHALMOSCOPY
requires wide pupillary dilation worn on the examiner’s head and allows binocular viewing through a set of lenses of fixed
power
A convex lens is hand-held several inches from the patient’s eye in precise orientation so as to simultaneously focus light onto
the retina and an image of the retina in midair between the patient and the examiner

OPTIC DISC
Normal: slightly oval vertically and pink in color
Central depression in the surface of the disc is called the “physiologic cup”
Look at the cup:disc ratio and note whether the cup takes up a large part of the disc
Note for any hemorrhages within the disc

RETINAL CIRCULATION
Composed of arteries and veins
Normal artery and vein ratio is 2:3
Arteries usually appear lighter in color than the veins and have more prominent light reflex from their surface

RETINAL BACKGROUND
Normal retinal background is a uniform red-orange color
The retinal pigment epithelium, blood and pigment of the choroid contribute to the appearance of the retinal background
One condition which changes this color is retinal detachment which prodcues a dull grayish appearance
MACULA
The normal macula is located temporal to the optic disc and appears darker than the surrounding retina
This is due to the specialized retinal pigment epithelial cells of the macula that are taller and more heavily pigmented
The center is the fovea which create a reflection known as foveal reflex