Eye PE

Question 1

Orbital Cellulitis Examination

Your next patient is a 7 year old/25 year old boy who has presented with swelling in his right eye. You have diagnosed him with orbital/periorbital cellulitis.

Task:
1. Explain your physical examination to the medical student with anatomical landmarks
2. Tell the medical student what you are looking for

Answer 1

I. Introduction
- Introduce yourself
- Explain steps: I’ll be looking at his eyes, checking his vision, eye movements & shining a light on his eyes
- Get consent
- Wash hands and start examination

II. Flagging
- The purpose of this physical examination is to differentiate orbital cellulitis from preseptal cellulitis. Orbital cellulitis is an infection that involves the orbit muscles and fat. Preseptal cellulitis is an infection of the anterior portion of the eyelid. This differentiation is important because the management is different, orbital cellulitis is an emergency. The most critical finding on PE that can confirm orbital cellulitis will be pain on eye movements. Orbital cellulitis is commonly caused by sinusitis which is an infection and inflammation of the nasal mucosa and sinus. 

III. General Appearance
- Level of consciousness
- Distressed due to pain
- Check temperature: expect fever in orbital cellulitis, and also look at the other vital signs

IV. Inspection
- Eyelid
	○ Redness, swelling
	○ Discharge
- Eyeball
	○ Proptosis: I'll be looking from above, looking for protrusion of the eye from the socket
	○ Redness, pattern of redness (localized, generalized, ciliary flush)
	○ Hypopyon, hyphema
- Pupils
	○ Size, symmetry
- Chemosis: swelling in the sclera and conjunctiva

V. Eye Exam
- The key step of this examination is to check eye movements
	a. Movement: ask the patient to keep the head still & follow the red top pin with his eyes, move your finger in an H shape pattern
		- I'll be checking for pain on movement, I expect pain on orbital cellulitis, and no pain on preseptal cellulitis
		- I'll also be checking for ophthalmoplegia: restriction in eye movements
		- If you find diplopia, do a cover test: close one eye at a time and check movement in the right and left eye separately
			□ Monoocular diplopia, which is most likely are case, diplopia will persist in the affected eye
			□ Binocular diplopia: normal eyes but they do not move together
	b. Pupil light reflex: shine a light on one eye
		- Direct reflex: constriction of the pupil in the same eye
		- Indirect reflex: constriction of the pupil in the opposite eye
		- In orbital cellulitis, I expect a possible abnormal pupil reflex
	c. Visual acuity
		- We use a Snellen chart/Pediatric Snellen chart at 6 meters distance
		- Ask patient to close one eye and start reading from the top line
		- Visual acuity will be reported as 6/6 or 6/60
			□ This means the patient can see the letter at 6 meters
			□ A normal person can see it at 60 meters
			□ If VA is abnormal, we can proceed to test with pinhole; if VA improves, it is suggestive of refractive error. In this case if VA is abnormal, pinhole will not improve the VA
			□ If the patient doesn't see the first line at 6 meters, move it closer to 3 meters, then to 1 meter, then counting fingers, then movements, then light perception
	d. Color vision
		- We use the Ishihara chart
		- Ask patient to close one eye and read the numbers in the colorful background
	e. Fundoscopy
		- This is the examination of the fundus and the optic nerve
		- Reduce lighting, use mydriatic drops
		- Ask patient to stare at a point on the opposite wall
		- Correct your and the patient's refractive error with the ophthalmoscope lens
		- Use the same hand for the same side of the eye
		- Set the lens to +20 to examine the cornea from 20cm away
		- Dial down to 0 while moving closer to the eye until the retina comes in focus

VI. Sinus Exam
- Inspect the nose with a speculum: look for discharge, swelling in the mucosa
- Check for sinus tenderness
	○ Press on the frontal sinus and maxillary sinus looking for tenderness
	
VII. Other Eye Exam
	f. Visual field: 
		- sit in front of the patient at 1 meter at the same level
		- Ask the patient to close 1 eye and close your opposite eye
		- Ask the patient to focus on your nose and not to move his head
		- Hold the pen in equal distance and compare your visual field with the patient
		- We will check both the temporal and nasal visual field
	g. Accommodation
		- Ask the patient to look at the opposite wall
		- Place your finger 20cm in front of the eye, then ask the patient to look at your finger
		- Look for constriction and convergence

VIII. Others
- Cervical lymph nodes: Palpate all the chains of the cervical lymph nodes
- Gentle palpation of the eyeball for tenderness
- Fluorescein staining: use strips or drops, use cobalt blue light