Opthalmology

Question 1

Visual Acuity

Answer 1

• Introduce, patient details, consent, wash hands
• Ask if they wear glasses/contact lenses and if they are for long or short vision. If they are for long vision let them keep them on
• Cover 1 eye and read lowest line possible, repeat on the other side
• Record 6/6 (top number is how far away they were, bottom number is how far away a normal person can read at) +/- number of letters they got correct on the next line
• If they can’t read 6/6 use pin hole if this improves vision they most likely have a refractive error
• If they can’t read anything on the 6m chart-> pinhole->3m->1m->count fingers->hand movements-> light perception
• Nomenclature: near sighted myopia, far sighted hyperopia, astigmatism football shaped eyebal resulting in refractive error across one part of the eye, prebyopia age related inability to focus on near objects
• Thank

Question 2

Opthalmoscopy (NOT FUNDOSCOPY )

Answer 2

• Introduce, patient details, consent, wash hands
• Ask if patient has had dilating drops, if yes use large light size if no use small light size
• Ask patient to focus on something in distance
• Turn lights off
• Right eye to right eye/left eye to left eye
• Stand back and look through fundoscope for red reflex
  
  • Absence of red reflex most likely cataract, but could also be something like vitreous haemorrhage
• Go in closer and examine the outer structures (eye lashes, eye lids, eye lid margin, conjunctiva, sclera, iris, pupil)
  
  • Look for signs of red eye, blepharitis, in turned eyelashes
• Place hand on patients eyebrow
• Go in w/ fundoscopy looking into nasal retina, find a vessel and focus on it. Follow it back to the optic disc
• Comment of colour cup and contour + vasculature
  
  • Cup to disc ratio should be 0.7, if more = glaucoma
  • If colour is pale = ischaemia
  • Look for dilated, constricted or neovasculature
• Ask patient to look up down left right and into the light looking for pathology in eye quadrant
  
  • Look for aneurysms, cotton wool spots, haemorrhages, IRMAs, laser scaring (usually the only thing that can look black)
• Repeat on other side
• Thank patient

FUNDOSCOPY IS ONLY LOOKING AT RED REFLEX AND RETINA

Question 3

Pupil reflexes

Answer 3

• Introduce, patient details, consent, wash hands
• Ask patient to look into distance
• In light examine pupils
  
  • Size
  • Shape
  • Colour
  • Level (look at corneal reflection)
  • Symmetry with each other
    
    • Looking for synechia (Iris stuck to lense), physiological anisocoria (pupils different sizes), manifest squint (corneal reflection different), nn palsy (eye will be looking if the direction away from the affected mm)
• In dark examine pupils again
  
  • Equal dilation
  • Symmetry with each other
    
    • Physiological anisocoria will be no more than 1mm different and will contract the same relative to each other
• Use light to check direct and consensual reflexes
  
  • Shine light in one eye and see if it constricts (direct)
  • Shine light in same eye and see if the other one constricts (consensual)
    
    • Looking for complete afferent pupil defect (dead optic nn eye will not constrict or give a consensual reflex), 3^rd nn palsy (eye looks out and down +/- unreactive dilated pupil), horner’s syndrome (ptosis, constricted pupil, dec sweating on one side), aide’s pupil (dilated pupil, delayed pupil reflexes, young patient, areflexia of knee and ankle)
• Preform swinging light test to check for RAPD
  
  • Hold light in the middle of the nose, shine it on one eye for 2 seconds then the other alternating
  • If the light on one eye causes both to dilate that eye has a RAPD Big eye in Bright light is Bad
• Check for accomodation
  
  • Ask patient to focus in distance then at something close eyes should converge and pupils constrict
    
    • Poor/no accommodation = 3^rd nn palsy
    • Slow accommodation = Aide’s pupil
• Thank patient

Question 4

Visual fields

Answer 4

• Introduce, patient details, consent, wash hands
• Sit knee to knee with patient
• Glasses off
• Test for macular degeneration/central scotoma
  
  • Ask if they can see your face, any parts missing
  • Tell them to keep focussing on your face and put your hands out palm out either side of your face like your raising hands for the police, ask the patient if your face or hands are clearer. Your face should be clearer
• Ask them to cover 1 eye and focus on your face
• Cover the same eye as them
• Hold up a number of fingers in all 4 quadrants of vision, fairly centrally, on that eye and ask them to tell you how many fingers. This is a crude way to see if there is a defect
• Repeat on other eye
• Testing peripheral vision: take white top pin and ask patient to tell you when they can see it and if it disappear at any point.
• Move to white pin from peripheral to central diagonally twice in each of the 4 quadrants ( 8 times per eye) remind the patient to keep talking to you
  
  • Use white pin as peripheral vision is composed of black and white visionàmacula colour vision
  • Nomenclature of missing visual fields
    
    • 1 quadrant = quandrantinopia (caused by lesion of lateral geniculate nucleus where optic tract splits into temporal and parietal)
    • 1 side = hemianopia
    • Both eyes affected in same way = homogenous
    • 1 eye affected = ipsilateral
    • Temporal sides affected = bitemporal (bitemporal hemianopia = pituitary pathology)
    • See picture attached for places the tract can be affected
• Repeat on other eye
• Testing macula: take red top pin and ask the patient to tell you when they see it, when it turns red and if they stop seeing it
• Move the pin from fairly peripherally (more central as not testing peripheral vision) to central again twice per quadrant. Remind the patient to keep talking to you
  
  • Use red pin because testing macular (colour vision)
  • Looking for central scotoma (macular degen)
• Repeat on other eye
• Offer to map blind spot
  
  • Ask patient to cover one eye, cover the same eye, place an object in your shared direct gaze (their pupil should be obscured)
  • Ask patient to tell you when the focal object disappears and slowly move it temporally
  • The object should disappear for both of you at the same time
• Thank patient

Question 5

Extra occular mm and eye movements

Answer 5

• Introduce, patient details, consent, wash hands
• Look at patient for signs of manifest squint using a light and corneal reflection
• Preform the cover uncover test again looking for manifest squint
  
  • Ask patient to focus on something fairly close to their face
  • Cover one eye and look at the other eye if it moves to focus on the object –> strabismus + the direction it moves in is the opposite of their squint
  • Uncover the eye and if it also it confirms there is a defect in the opposite eye and the uncovered one is the dominant refocusing
  • Do the same on the other side, in a single sided manifest squint this will not yield any results
  • If there is a nn palsy the affected will not correct and focus on the object
  • Nomenclature:
    
    • manifest = …..trophia
    • latent = …..phoria
    • inward = eso…
    • outward = exo
    • up = hyper
    • down = hypo
• Then preform the alternate cover test, when an eye is uncovered see if it moves, if yes latent squint in the direction opposite to the movement. Cannot tell which side a latent squint arises from.
• Test eye movements in a star shaped fashion, w/ each movement taking the eye to the edge so no sclera is visible, making sure head stays still, ask patient to report any double vision
  
  • Here looking to see if the movement is possible (nn palsy)
  • Pursuit is normal
  • Any nystagmus
• Thank patient