Ocular Diagnostics

Question 1

Eye Vitals

Answer 1

*Visual Acuity
*Pupillary Exam
Visual Fields
Ocular Motility
*Tonometry
Exam

Question 2

Visual Acuity Tools

Answer 2

Distance: Snellen
Near: Rosenbaum card
Tumbling E
3-7 yr olds: HOTV
Good for kids/illiteracy: Allen picture chart
Preverbal/nonverbal: Fixes & follows, central/steady/maintains

Question 3

Snellen Chart

Answer 3

Recorded as ratio
Numerator is distance from chart (feet or m)
Denominator is distance at which letters can be read by person w/ unimpaired vision
(e.g. 20/70 means you can see at 20 feet what “normal” vision sees at 70 feet)

Question 4

Rosenbaum chart

Answer 4

Held 14 inches from face
Recorded as ratio or Jaeger number.
Ratio is easier for patients to understand, you to explain and widely used by ophthalmologists

Question 5

VA

Answer 5

visual acuity

Question 6

CC

Answer 6

w/ glasses (correction)

Question 7

SC

Answer 7

without glasses (w/o correction)

Question 8

OD

Answer 8

right eye (oculus dexter)

Question 9

OS

Answer 9

left eye (oculus sinister)

Question 10

OU

Answer 10

both eyes (oculus uterque

Question 11

Which eye is conventionally recorded first?

Answer 11

RIGHT (OD)

Question 12

What to do if patient can’t see largest letter on eye chart…

Answer 12

1. REDUCE DISTANCE to chart
2. No letters @ <3ft? –> COUNT FINGERS (CF)
3. No fingers? HAND MOTION (HM)
4. No movement? PRESENCE of LIGHT (LP)
5. No light? NO LIGHT PERCEPTION (NLP)

Question 13

Pinhole occluder

Answer 13

Pinholes correct for refractive error (dry eyes, cataracts)

Question 14

PERRLA

Answer 14

Pupils equal, round, reactive to light

Direct? Consensual?

Question 15

Relative afferent pupillary defect

Answer 15

Swinging flashlight test
Abnormal response: Dilation rather than constriction
Indicates lesion of nerve on affected side

Question 16

Eyes follow 6 cardinal directions

Answer 16

Right, up
Right
Right, down
Left, up
Left
Left, down

Question 17

Right, up muscles

Answer 17

Right superior rectus

Left inferior oblique

Question 18

Right muscles

Answer 18

Right lateral rectus

Left medial rectus

Question 19

Right, down muscles

Answer 19

Right inferior rectus

L superior oblique

Question 20

Left, up muscles

Answer 20

Left superior rectus

Right inferior oblique

Question 21

Left muscles

Answer 21

Left lower rectus

Right middle rectus

Question 22

Left, down muscles

Answer 22

Left inferior oblique

Right superior oblique

Question 23

Strabismus

Answer 23

Misaligned Eyes

One eye w/ limited movement, Both eyes limited movement together, Nystagmus

Question 24

Nystagmus

Answer 24

Dancing eyes (oxoclonus/myoclonus –> strong correlation w/ neuroblastoma)

Question 25

Esotropia

Answer 25

Eye deviated medially

Question 26

Exotropia

Answer 26

Eye deviated laterally

Question 27

Hypertropia

Answer 27

Eye deviated superiorally

Question 28

Hypotropia

Answer 28

Eye deviated inferiorally

Question 29

Confrontation visual fields

Answer 29

Tests peripheral vision for gross defects only

Question 30

Tonometry

Answer 30

Measures intraocular pressure Helpful for glaucoma screening Start w/ drop of proparacaine/tetracaine TIPS: tell patient to breathe normally & don't push on globe

Question 31

Normal IOP

Answer 31

10-21 mm Hg

Question 32

External Eye Inspection

Answer 32

Inspect eyelids and eyelashes (bruising, swelling, mattering) Tearing Rashes or skin lesions Inspect conjunctiva/sclera (penlight or muscle light) Palpate orbit Palpate lymph nodes

Question 33

Slit lamp exam

Answer 33

Binocular microscope 3D view of eye Most useful to look at anterior eye (Corneal abrasions, foreign bodies, trauma) *Can use fluorescein*

Question 34

Fluorescein staining

Answer 34

Looks at defect in corneal epithelium Use anesthetic drop first Remove contacts first!! (Can stain)

Question 35

Eyelid inversion

Answer 35

Suspected foreign bodies Vertical defect w/ fluorescein staining *Have patient look down, pull lid inferiorly/anteriorly and rotate superiorly over CTA*

Question 36

Ophthalmoscope Evaluates For

Answer 36

``` Red reflex Optic disc Retinal circulation Retinal background Macula (if you're impressive) ```

Question 37

Cotton wool spots

Answer 37

Signs of ischemia or infarct in retina

Question 38

Blood & Thunder

Answer 38

Vein occlusion & edema in eye | Typically due to HTN

Question 39

Amsler Grid

Answer 39

Evaluates visual distortion w/ grid (for macular degeneration or other visual distortion) Visual field defects Central field defects

Question 40

Metamorphopsia

Answer 40

Visual Distortion

Question 41

Scotoma

Answer 41

Blind spot

Question 42

CT for eyes

Answer 42

Always in traumas | Infection? Do CT w/ contrast

Question 43

MRI for eyes

Answer 43

w/ and w/o contrast good for neural structures *Make sure to do "fat suppression"* IIH? MRI w/ MRV to look @ venous system

Question 44

Fluorescein angiography for eye

Answer 44

Evaluate retinal bloodflow (leakage) | Central serous retinopathy, macular degeneration

Question 45

Ultrasonography for eye

Answer 45

Large black circle is vitreous humor | See detached retina (line through vitreous humor)

Question 46

OCT

Answer 46

Optical coherence tomography Infrared light penetrates retina Can see downt o 10-15 microns Can distinguish 15 layers of retina

Question 47

When to refer pt. w/ reduced visual acuity?

Answer 47

Worse than 20/20 (or documented baseline) w/ visual symptoms in one or both eyes Worse than 20/40 in both eyes w/out symptoms Assymetry (difference of 2+ lines on Snellen chart) Pesbyopia (reduced near vision w/ no change in distance)

Question 48

When to refer abnormal fundus appearance?

Answer 48

Wide range of normal Use discretion & resources Don't be afraid to reach out to ophtho

Question 49

When to refer elevated IOP?

Answer 49

>22mm Hg