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M11: Ophthalmology Module [Ophthalmology]

HISTORY-TAKING & BASIC OPHTHALMOLOGY EXAM

13 October 2011 Johann Micheal G. Reyes, M.D. A. CHIEF COMPLAINT Should be recorded in the patients own words - Filipinos complain about everything so focus on the primary symptom alin ang nangingibabaw? Dont mention suggestive terms Dont employ medical terms as much as possible: - Example: use redness, burning, light flashes instead of conjunctivitis - Patients may have more than one chief complaint o May list down all, even minor ones o Major complaint should be emphasized - It is best to ask first what the patient came in for that prompted consult because they will inevitably say yes to all symptoms if you present it to them in a list-wise fashion - Look for CC; which may not be initially offered i.e. cosmetic concerns over vision impairment B. HISTORY OF PRESENT ILLNESS Expound of chief complaint using focused questions General areas of inquiry: - Time and manner of onset: Sudden vs. Gradual, progressive vs fluctuating - Severity: worsened, improved, remained the same - Influences: what circumstances precipitated the condition, made it worse or better? - Important to ask about previous ocular medications o i.e. Anong ginagawa nyo noong naramdaman ninyo iyon? o Ask circumstances when symptoms appeared o Ask especially when symptoms are non-specific - Constancy and Temporal Variations: intermittent? Seasonal? Worsens during a particular time of the day? - Laterality: One or Two eyes? (sometimes included in chief complaint) - Documentation: Previous Recordsvery important especially if they had previous medications/drops o Filipinos dont usually bring documents during documentation, but you can ask for anything on hand that they can give to help you in your diagnosis. If not available, ask about previous consults. General categories of complaints - Disturbances in vision - Most common complaint o Blurring: central or peripheral ( peripheral is very hard to notice); two entities are suggestive of different diseases o Altered images: macropsia (sees things bigger than things usually are), micropsia (sees things smaller than things usually are), metamorphosia (distorted images) o Diplopia o Floaters (disturbing spots in the visual field) o Photopsias (light flashes) o Iridescent vision (halos, rainbows) o Color vision abnormalities (some conditions are more common in males, ex: color blindness) o Blindness - Ocular pain and discomfortvery hard to characterize because pain in the eye can mean anything o Foreign body sensation: scratchy feeling, states that there seems to be a particle in eye

OUTLINE: I. Ophthalmic Evaluation II. History Taking A. Chief Complaint B. History of Present Illness C. Past Ocular History D. General Medical/Surgical History E. Personal/Social History F. Family History III. Basic Eye Exam A. Visual Acuity (VA) B. Gross Examination C. Extraocular Muscles D. Tonometry E. Fundoscopy IV. Summary of Findings

Italicized: Audio : Research

I. OPTHALMIC EVALUATION Purpose includes: - Obtain an accurate ocular (and systemic) history o We dont stop there, we determine if there are related systemic diseases - Determine health status of the eye and related structures - Identify risk factors for ocular and systemic disease - Detect and diagnose ocular abnormalitiesfor referral purposes - Document the presence or absence of systemic disease in relation to eye findings - Discuss findings with patient - Initiate appropriate response Most ophthalmic diseases can be diagnosed by history alone. The length of the history is not important and completeness and succinctness is better. It is important to check other systems during history taking because many systemic diseases have ophthalmologic manifestations. For example, patients with chief complaint of sudden loss of vision may be due to artery blockage. The first consult may be an eye consult. The end point of the ophthalmologic consult is to manage the patient.

II. HISTORY TAKING Ophthalmic history emphasizes: - Symptoms of ocular disease - Present and past ocular problems - Ocular medicationsremember to ask about this Components of the history: - Chief complaint - Present illness - Past ocular history (i.e. Ocular medications) - General medical and surgical history o Systemic medications/allergies - Personal/social historysupport system - Family history

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HISTORY TAKING & BASIC OPHTHALMOLOGY EXAM o Ciliary/deep pain: compressive, can radiate to head or present with headache parang humihilab like the eyes being compressed; pasma o Photophobia: pain on light exposure especially in patients with migraine o Burningmore generalized o Dryness Very nonspecific; often described as magaspang while blinking o Itching: true itching compels patient to rub eyes (consider allergy) o Asthenopia: eye strain/ tired eyesvery very common now o Pain is felt because of irritation from the nerves o Deep pain is often suggestive of increased ICP (glaucoma or increased intraocular pressure, IOP, can also present with pain) o Dry eyes is usually rarely complained as dry eyes, and usually manifested in nonspecific signs such as itchiness and urge to rub o The more you scratch your eyes, the more histamine is released; scratchiness with redness is suggestive of allergies. - Abnormal Ocular secretions o Lacrimation: tearing, welling up of tears on surface Not necessarily increased production, may be abnormal accumulation of secretions Feeling that the eyes are always overly moist without necessarily spilling over or tearing o Epiphora: actual spilling of tears down the face (Usually from blockage) o Discharge: Purulent Mucoid Mucopurulent (suggestive of bacterial conjunctivitis) Watery Stringy watery secretions are almost pathognomonic for allergy. This is seen when you press a cotton applicator and secretions appear stringy when you remove it. Itchiness + stringy discharge (remember STRINGY for the EXAM) - Abnormal appearancesvery common especially since cosmetic / very visible o Patients do not usually come to clinics because of dryness, but because of aesthetic concerns o Ptosis (drooping lids) o Proptosis/ exophthalmos o Enopthalmos (eyes recessing into the sockets) o Blepharitis/ matted lashes with crusting (eyelashes look as if they have dandruff) o Eye misalignment o Redness, other discolorations (suggestive of subconjunctival hemorrhage) o Masses such as a sty or kuliti o Anisocoria (inequality of pupils) usually an incidental finding - Other complaints o Second opinion: ex. Diabetic and hypertensive patients a lot of patients are seen because of this to assess if the

OPHTHALMOLOGY

patients are being given adequate control of their diseases. - Trauma o Obtain information on: DOI TOI POI MOI Date, Time, Place- this and manner of injury are the most important parts of the history in trauma Manner of injury Injurious agent (chemical, objectbe specific)very rare ophtha emergencies Emergency measures instituted Patients usually have gone through other hospitals and doctors already. It is important for your management to know other treatments that were given. Symptoms especially effect on vision In severe trauma, vision can change over time. Documenting vision for progression is important. Test the vision right away when the patient is stable enough. C. PAST OCULAR HISTORY Ask about previous eye problems (a basic general question) be curios, not nosey Use of eyeglasses or contact lensesask when they began wearing corrective implements Date of most recent eye consult or refraction Any ocular surgeries Previous ocular trauma History of visual problems in childhood Use of ocular medications: - Know how patient responded to prior therapy - Recent therapy can affect patients status - All past and current medications should be recorded In viral conjunctivitis, Eye-Mo drops can mask the appearance of symptoms and promote the spread of infection. It would be best to advise consultation with ophthalmologists ASAP instead of symptomatic treatment. Findings are usually affected by what patients already put in their eyes so ask about them D. GENERAL MEDICAL AND SURGICAL HISTORY Many ocular diseases are manifestations of, or associated with, systemic diseases (ex. Diabetic retinopathy) General medical status of a patient must be known to perform a proper preoperative evaluation (ex. Some drops may cause HPNsuch as phenylephrine which is given to dilate the eye) Note date of onset, previous treatments and response to treatment If pediatric: may ask mother about pregnancy, prenatal care, use of drugs, difficulty in laborfor forceps injury or perinatal trauma/incidents even if they present as adults already etc. Systemic medications: - Can cause ocular, preoperative, intraoperative and postoperative problems - Ex. Give aspirin and anticoagulants - Give an idea of how to control underlying disease o Some dilating drugs have an effect on hypertension: there may be a need to give BP lowering meds just to dilate the eyes.
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HISTORY TAKING & BASIC OPHTHALMOLOGY EXAM o The conjunctiva can bleed when touched especially if patients are on anti-coagulants o Ask about other diseases such as diabetes and patients control of disease (be strict about this because some do not know about their condition, or some have not consulted about their disease and just self-medicate; this can have a profound effect on management) Allergies: - Avoid drugs patient is allergic to. If you are allergic to drugs but you keep on using it for the eyes, you may get contact dermatitis. - Sensitivity to environmental agents (dust, mites) - History of asthma, atopic dermatitis, urticaria/hives E. PERSONAL/ SOCIAL HISTORY Not always necessary When relevant, may ask about: - Smoking, alcohol and drug abuse - Sexual history- can have STDs that present with eye symptoms, such as ophthalmia neonatorum o Remember chlamydia and gonorrhea go hand in hand; ask patient in private if necessary F. FAMILY HISTORY Important when genetically transmitted disorders are under consideration (Ex. corneal dystrophies) Ask for history of ocular disease in family members other than spectacle correction/error of refraction May ask predisposition to other systemic diseases which have genetic correlations: - DMif the patient hasnt consulted yet but you suspect it, just write unknown and then refer. - Malignancies - Thyroid disease Inability to provide information on family background should not be recorded as negative - Record as unreliable source or insufficient information gathered G. REMINDERS Details more important than length Too many details may sacrifice substance or deviate from actual complaint Ask focused questions If warranted, may also consult parents, relatives or guardians Always conduct interview with proper demeanor Remember to have respect for patient at all times Focus on chief complaint then expound, then get the associated symptoms

OPHTHALMOLOGY

III. BASIC EYE EXAM (VAGET-FSL) SL is slit lamp so its not done by clerks/interns The 2 true ocular emergencies: chemical burn (opt to irrigate first before testing for visual acuity) and CRAO (Central Retinal Artery Occlusion)

A. VISUAL ACUITY This is checked prior to touching the patients eyes unless its an emergency; this is the most challenging part according to sir Measurement - Snellen notation is most standard; results are written as a fraction in meters or feet - Numerator: testing distance from eye to chart - Denominator: Distance an unimpaired eye can resolve the same figure; the bigger the denominator, the worse the visual impairment. o 20/20: Subject can read at 20 feet what a normal/unimpaired eye can read at 20 feet o 20/40: Subject can read at 20 feet what a normal/unimpaired eye can read at 40 feet o 20/200: Subject can read at 20 feet what a normal/unimpaired eye can read at 200 feet o 6/6: subject can read at 6 meters what a normal/unimpaired eye can read at 6 meters o 6/12: subject can read at 6 meters what a normal/unimpaired eye can read at 12 meters o 6/60: Subject can read at 6 meters what a normal/unimpaired eye can read at 50 meters Testing Targets: primary mode is by using Snellen Chart - Variations: o HOTV: used only because patients have memorized the Snellen chart; usually randomly flashed from projectors since patients have memorized the Snellen chart already o Projector: so patient has no anticipation of what will come out - VA can be measured either in meters or feet - If the patient is not able to read all the letters in a given line: o Record this as + or number of letters not read (ex. If 1 letter was read wrong in a line from 20/40, then state 20/40 1) - Use the same principle if feet are the units! - Crucial Number: 50% of numbers on a part IF patient is unable to read the 6/6 line at 6 meters: o Move the patient closer to a distance (at 1 meter intervals) just enough for the patient to be able to read just the first line VA measurement: numerator is replaced with the line where the patient is able to see the first line Ex: if a patient is at 3 meters and can read E, FP, move the patient back until he or she can only read the E. If patient is closer than 6 meters (numerator is <6), the denominator should always be >60. Move the patient only until the patient can read the first letter Same principle for meters and feet - If patient cannot read the first line (6/60 or 20/200) at 1 meter finger counting is done o Finger counter is not done at a distance of 6 meters or more o Usually finger counting is done at 1,2,3 feet o Express visual acuity as: VA=CF at 1 foot, 2 feet, or 3 feet o Use open palm o Dont move too close to subjects face o Ensure adequate occlusion of the other eye o Hand motion is based on the principle that hand movement blocks light. Those without vision are sensitive
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HISTORY TAKING & BASIC OPHTHALMOLOGY EXAM to touch and air differences so make sure you are of adequate distance to the patient. o Patient moves closer only up till the distance where he can read the E. If the patient is one meter away and still cannot read the E, do finger counting. o If the patient still cannot count fingers, then do hand movement tests. These patients visualize based on the change in light. Use an open palm, dont move too close because they are very astute with their other senses i.e. they can feel the air moving when you move your hand If the patient can recognize hand movement, shine light in four quadrants (X-formation, not cross) o If youve established that the patient can sense eye motion, get a penlight and shine the light from each of the four quadrants. o Done by covering one eye and asking if movement is seen. Light is also shone on 4 quadrants and patient is asked to point where the light is coming from. o This is important to do because with pure media opacity (cataract), your worst vision is basically good light. If light seen is fair or poor, you should expect a nerve problem or other disease entities. If there is no light perception: end point, eye is dead o Record visual acuity as: (+) HM with good/fair/poor light projection Good: 4 quadrants If the patient cannot distinguish fingers, do hand movement/hand motions o Opacity: at worst, good light projection o Nerve problems: Fair or Poor light (something at the back thats going on) If hand motions are not recognized o Shine a light and determine if subject can perceive light perception o Record as either (+) LP or NLP Sequence of Visual acuity testing o One eye at a time, usually right eye is tested first, followed by the left o Use an occluder to cover the eye not being tested o Unless with previously documented or poor vision, subjects are always tested with the Snellen chart first 1. Begin with no visual aids (Spectacles) Snellen chart at 6 meters or 20 feet move close until subject can read first line only finger counting Hand movement with light projection Light perception 2. Have a patient read through a pinhole after a. Pinhole: can opt to do this before making the patient move closer to the Snellen chart 2.4 mm diameter or any size of hole smaller than the pupil Admits only central light rays If vision improves two lines or more, chances are, the patient has a refractive error/will need glasses o Uses the same principle as squinting or using the smallest aperture in photography. Light rays are more focused so you can see farther distance. If a patient has cataract, vision will not improve on pinhole. If it improves two lines or more, it is most likely a refractive error and can be

OPHTHALMOLOGY

corrected with glasses. Otherwise, it might be a cataract or other diseases. b. If the patient wears spectacles Test without eyeglasses first Without eyeglasses, with pinhole Have patient wear eyeglasses Check VA with lasses and pinhole (If cannot read up to 20/20 line with eyeglasses) B. NEAR VISION TESTING Important for: - Patient who are 40 years old and above (presbyopia) - Bedridden patients - As you get older, your lens dont a ccommodate anymore so you will need corrective lenses Tested at 14-16 inches (40 cm) Record visual acuity as Jaeger notation (Ex: J16, etc.) VA OD: right eye OS: left eye OU: both eyes; ask patient to use two eyes to read summative effect NIPH: not improved with pinhole; so only note effect if it improved vision C. VISUAL ACUITY TESTING IN INFANTS AND SPECIAL ADULTS When testing VA in infants - Make sure that the only stimulus being used is visual (no auditory stimuli e.g. Bells) - Observe if infant becomes irritable when one eye is covered compared to the other - Record VA as: o (+) or (-) dazzle (silaw) - For older children who can follow instructions already: Centered, steady, maintained (no nystagmic movement when you move the light, the eyes follow), able to fixate, follows object Illiterate patients - Tumbling Ejust say which direction the letter E is so so language/ alphabet differences is not a problem i.e. in Japan Japanese characters - Landolt C - Allen Picture Chartjust naming i.e. bird, cake etc. - Basic principle employed by all: you will make the patient point to the direction of those seen in the chart

Landolt C

Tumbling E

Allen Picture Chart

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HISTORY TAKING & BASIC OPHTHALMOLOGY EXAM D. GROSS EXAM Check eyelids, and eyelash, check position of lids Check for proptosis, exophthalmos Basically look at the eyes and draw what you see Pupil size, equally brisk and reactive to light +/- RAPD (relative afferent papillary defect) - Masses, redness, cataract, lashes matting, crusting Corneal Light Reflex/Hirchbergs Reflex - Test of eye alignment - Shine a light into the eyes, the reflection of the eyes should fall directly on top of the center of the pupils:

OPHTHALMOLOGY

What if the patient is blind? Just tap the patient in the different directions Review the muscles involved per position Recording EOM test results: - The orientation of the drawing is the patient looking at you - 3 diagrams (OD OS OU) F. TONOMETRY To determine intraocular pressureimportant in cases of glaucoma. Schiotz device: used in the past; with predetermined weights Applanation: used now (blue light done under anesthesia) Finger tonometry/digital/palpation tonometry - Normal IOP 8-21 mmHg (Goldmann applanation tonometer) - Use both index fingers and ask the patient to look down and NOT to close their eyes (stay in front of the patient; emphasis on not closing eyes because this will induce Bells reflex) - Report findings as: o Report as either hypotonic (as soft as the lips) /hypertonic (firm as the forehead), soft/firm/hard - Note: If open globe injury is suspected, defer palpation; DONT do finger tonometry if you arent sure if palpation will cause further harm. G. FUNDOSCOPY 1. Indirect Ophthalmoscopy - 2-5x magnification - Able to see peripheral retina - Inverted image 2. Direct Ophthalmoscopy - Performed with the eye corresponding to the eye that is being examined (right to right, left to left) - Remember to explain to the patient what you are about to do as well as instruct him properly to not look at the opthalmoscope or else the light will just bounce back at you. Move closer at an angle. - Conventionally, right eye is examined first. - Ask the patient to look straight at a fixed target. - Shine light from a distance of 2 feet to check red orange reflex - Move closer to patient at an angle of about 15 degrees - Move close until you see the vessels - The vessel become bigger as you come closer to the disc - Check media - Check disc (difference of O.2 in CD ration between eyes is suspicious) - Findings: o Red orange reflex: (+) or (-), a must! o Media: Whether the ROR is clear or not clear (when you see structures right away) or hazy (seen in cases of cataract) o Disc Borders: Distinct or indistinct (sign of papilledema) If the borders are indistinct, you dont have to do cupto-disc ratio anymore (i.e. in papilledema) o Cup-Disc Ratio: 0.3-1.0, normal is <0.5 The cup is the area of pallor as compared to the whole thing. If there is a great cup-disc ratio, it is a sign of glaucoma. But this can be normal in some patients.
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- If the reflex is outer, or lateral to the pupils, it means that the eye is deviated medially (ESO) o ESO: inward o EXO: outward In left esotropia, the left eye is deviated medially; therefore the reflection/shine of light is seen on the outer-lateral side the reflex which should be at the center is outside/lateral; it is pushed medially. In right exotropia, the right eye is deviated laterally In drawing the eyes schematically, make sure that the lower limbus is connected to the lower lid. The higher limbus can be 1 mm above the higher lid margin. Reporting Gross Eye Exam Findings: - Drawing of the physical eye (schematic) - +/-RAPD: Marcus Gunn; Relative Afferent Pupillary Defect (RAPD)indicate underlying neurological problem - Shade and draw lesions such as redness, cataracts etc.

E. EXTRAOCULAR MUSCLES Test by having the eye/s follow your finger Evaluate the eye muscles: 4 recti, 2 obliques - Weaknesses - Deviations Positions of gaze Sit facing the patient Hold finger or small fixation target at eye level and move in an H maneuver Report: - Right eye: arrows - Left eye: circles - Both Eyes: overlap

It is important to note the endpoint in figures to show that the eye does not move lateral or medial enough No inferior and superior directions These are the cardinal positions of gaze Dont forget to indicate the maximum limits of gaze

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HISTORY TAKING & BASIC OPHTHALMOLOGY EXAM What is important is the difference between the two eyes. In glaucoma, the area of pallor (cup) is bigger so the cup to disc ratio increases. o A-V Ratio: Normal is 2:3, in Hypertensives: 1:2, 1:3 In hypertensives, it is the artery that decreases in caliber. Artery: Vein diameter/ width o Hemorrhages and exudates: (+) or (-); exudates will be yellowish spots Extraocular Muscles

OPHTHALMOLOGY

Left: Hemorrhage in the superior half of the retina; Right: Yellow spots are exudates o Foveal Reflex: Good or Dull; when you visualize the fovea there will be a sparkle of light but this is hard to find. Reporting the findings in a normal eye: - (+) ROR, CM, DDB, CD 0.3, AV 2:3, (-) H/E, Good FR - If you dont see it, dont declare it!!! H. SUMMARY OF FINDINGS VA: without correction with PH, with correction with PH G: Drawing: 3mm EBTRL (equally brisk and reactive to light)

IV.

SUMMARY Remember to make an accurate and detailed history Ophthalmic PE: new skill set, needs to be developed Do not neglect systemic conditions and their possible relationships to the eye condition If you dont see it, dont report it Practice makes perfect!

Appendix Parts of the Retina on Fundoscopy

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