A complete history includes four aspects: Family history (refractive errors, strabismus, cataract, glaucoma, retinal detachment, retinal dystrophy) Medical history: - systemic disorders (diabetes mellitus, hypertension, infectious diseases, rheumatic disorders, skin diseases)
- medications (steroids, chloroquine, Amiodarone, Myambutol, chlorpromazine)
Ophthalmic history: strabismus, amblyopia, corrective lenses, posttraumatic conditions, surgery, eye inflammation Current history: What symptoms does the patient present with? (impaired vision, pain, redness of the eye, double vision) 2. Visual acuity The sharpness of near and distance vision is tested separetly for each eye. Uncorrected and corrected visual acuity are tested using Snellen chart. It is a universal standard used by most clinicians. The patients is asked to recognize special symbols called optotypes. VA is a fraction in which the numerator indicates the distance of the patient from the chart and the dominator indicates distance at which a normal eye can read the line. Visual acuity = actual distance standard distance Normal VA is 5/5 (20/20) or 1.0 when the actual distance equals the standard distance. Plus lenses (convex lenses) are used farsightedness ( hypermetropia) and minus lenses for nearsightness (myopia) and cylindrical lenses for astigmatism. If the patient cannot discern the symbols on the eye chart of 5 meters (20 feets) the examiner shows the patient the chart at a distance of 1 meter or 3 feet. If the patient is still unable to discern any symbols the examiner has the patient count fingers, discern the direction of hand motion and discern of a point light source. CF count fingers, HM hand movements, PL perception of light, NPL no perception of light. 3. Maesurement of Intraocular Pressure Palpation: comperative palpation of both eyeballs that can detect increased intraocular pressure. The the examiner places his fingers on the patient’s head and palpates the eye through the upper eyelid with both index fingers. The test is repeated on the contralateral eye for the comparison. Schiötz indentation tonometry: The examination measures the degree to which cornea can be indented in the supine patient. The lower the intraocular pressure the deeper the tonometer pin sinks and the greater distance the needle moves. The
harder the eyeball the shallower the indentation and the smaller the movement of indicator needle. The tonometer is placed on the anesthetized cornea. Applanation tonometry: This method is the most common method of measuring intraocular pressure. It is a slit lamp measurement of intraocular pressure. We put anestheszing eyedrops and fluorescein drops into conjunctival sacc and then the tonometer tip is placed on the cornea. The cornea is applanted (flattened) over an area measuring precisely 7,35 mm². This external pressure required is directly proportional to intraocular pressure. Pneumatic non contact tonometry: The electronic tonometer directs a 3 ms blast of air against the cornea. The tonometer records the deflection of the cornea and calculates the intraocular pressure on the basis of this deformation. 4. Examination of nasolacrimal duct: Conjunctival fluorescein dye test: It is tested by instilling 10% fluorescein solution in the conjunctival sac of the eye. If the dye is present in nasal mucus expelled into paper tissue after 2 minutes the lacrimal duct is open. Probing and irrigation: They are used to locate stenoses. The punctum is dilated by rotating a conical probe. Then the lacrimal passage is flushed with a physiologic saline solution. Schirmer tear testing: This test provides information on the quantity of watery component in tear secretion. A strip of litmus paper is inserted into the conjunctival sac of the temporal third of the lower eyelid. After about 5 minutes at least 15 mm of paper should turn blue due to the alkaline tear fluid. Values less than 5 mm are abnormal. Tear break – up time: This test evaluates stabillity of the tear film. Fluorescein dye is added to the corneal tear film. The examiner observes the eye with a slit lamp and cobalt blue filter and notes when the first signs of drying occur without the patient closing the eye. Normal TBUT of at least 10 sec. 5. External examination ( orbital area, eyelids, ocular motility). a. Orbital cavity. Palpation of the orbital rim and lids. Unilateral or bilateral enophthalmos ( recession of the eyeball within the orbital cavity) or exophthalmos ( protrusion of the eyeball). Exophthalmometry: The Hertel mirror exophtlalmometer measures the anterior projection of the globe beyond the orbital rim. The devices measures prominence of the eye from anterior surface of the cornea to the temporal bony rim of the orbit. The exophtalmometer is placed on the lowest point of the temporal zygomatic. The examiner reads the value of the extraorbital prominence of the anterior surface of the cornea on the scale. The difference between the two sides greater than 2 mm is abnormal. b. Ocular motility. With the patient’s head immobilized the examiner asks the patient to look in each of nine diagnostic positions of gaze(straight ahead, right, upper light, up, upper left,
down, lower down…), This allows the examiner to diagnose strabismus, paralysis of ocular muscles and gaze paresis. c. The lids. The shape, eyelid position, skin of the eyelid, width of the palpebral fissure. When the eye is open and looking straight ahead the upper lid should cover the superior margin of the cornea by about 2 mm. If more then ptosis of that lid may be present. We should note if the lids evert or invert. When the lower lid is turned away from the eye ectropion is present. When the lid is turned inward toward the globe the entropion is present. The width of the palpebral fissure is normally 6-10 mm and the distance between the lateral and medial angles is 28-30 mm. To evaluate the palpebral conjunctiva we can do simple eversion of the upper and lower eyelid. In this way we can also evaluate the superior and inferior fornix. The patient relaxes and look down. The examiner places a swab superior to the tarsal region of the upper eyelid, grasps the eyelashes of the upper eyelid between the thumb and the forefinger and everts the eyelid using the swab ac a fulcrum. This same we can perform using finger or Desmarres eyelid retractor. When we examine the lower eyelid the patient looks up and the examiners pulls the eyelid downward close to the anterior segment. 6. The examination of anterior segment of the eye ( the conjunctiva, cornea, anterior chamber, iris, lens, pupil, anterior part of the vitreous body). a. Conjunctiva The bulbar conjunctiva can be evaluated by direct inspection under a focused light. Normally it is shiny and transparent. The other parts of the conjunctiva will not be normally visible. They can be inspected by everting the upper or lower eyelid. b. Cornea
• Slit lamp examination
• Fluorescein staining of cornea – it is useful in diagnosing defects of corneal
epithelium. Illumination with a cobalt blue filter enhances the fluorescent effect. This dye method can reveal corneal epithelial defect (corneal erosion).
Corneal topography – the keratoscope (Placido’s disk) permits gross evaluation of the uniformity of the surface of the cornea. This instrument consists of a round disk marked with concentric black and white rings around a central aperture. The examiner holds the disk in his hand and looks through the aperture. The surface of the cornea is now normally evaluated by computerized corneal topography (videoceratoscopy). In this examination the contours of the cornea are measured by a computer in the same manner as keratoscope.
• Determining corneal sensitivity – corneal sensitivity can be evaluated with a
distendend cotton swab. The patients looks straight ahead while the examiner holds the upper eyelid and touches the cornea anteriorly. Decreased sensitivity can provide information about trigeminal or facial neuropathy or may be a sign of a viral infection of the cornea.
• Measuring the density of the corneal endothelium – specular microscopy
permits a precise endothelial cell count while simultaneously measuring the thickness of the cornea (pachymetry). A sufficiently high density of endothelial
cells is very important for the transparency of the cornea. More than 2000 per mm² is normal.
• Corneal pachymetry – measurement of the thickness of the cornea.
c. Anterior chamber The anterior chamber is filled with clear aqueous humor. It is important to evaluate the depth of the anterior chamber. d. Iris Slit lamp examination – we evaluate surface structure – crypts and trabeculae e. Pupil Pupil size and shape Testing the light reflex – direct light reflex, indirect light reflex. f. Gonioscopy and morphology of the anterior chamber angle angle structures. The angle of the anterior chamber is evaluated with gonioscope placed directly on the cornea. Gonioscopic image of the angle – Schwalbe’s line (end of Descemet’s membrane), trabecular meshwork, Schlem’s canal, scleral spur, the ciliary body band. g. Vitreous body - slit lamp examination, ultrasonography, ophthalmoscopy 7. Examination of the fundus of the eye – ophthalmoscopy. It permits the visualization of the optic disc, arteries, veins, and retina. Adequate papillary dilatation is necessary. Optic disc margin should be sharp and well defined. It is about 1,5 mm. Amsler grid testing – is a useful method of evaluating the function of the macula. This test is carried out by having the patient look with one eye at a central spot on a page with horizontal and vertical parallel lines. The patient is asked to note irregularities in the lines. Irregularities may be reported as lines that are wavy, seem to bow or bend. 8. Additional examinations in ophthalmology – fluorescein and indocyanine angiography, electrophysiology, ultrasonography, computerized tomography, MRI, color vision testing, visual field examination. a. Color vision testing There are two types of retinal fotoreceptors called rods and cones. Cones are placed in macular area and rods peripherally in the retina. Cones are responsible for daytime vision – fotopic vision and color vision and rods are responsible for night or scotopic vision. Three sets of cones: the first one consists of longer wave length sensitive cones – L cones. The second set consists of more middle sensitive cones – M cones. The third – short wave length. S cones. It depends on the max sensitivity of photopigments or on the max absorbtion of the visible light spectrum. The visible light spectrum ranges from 380 – 670 nm. There are three basal colors and the other hues are the mixture of them. Red/green color vision defects are often seen in optic nerve
or inner retinal disease. Blue/yellow defects are seen in outer retinal layer (macula) and more peripheral retina.
• Ishihara plates – it is a qualitive test. The book contains different patterns,
letters, shapes and numbers composed of small color dots surrounded by confusion colors. The patient with color vision defects cannot read these letters.
• Panel D15 – Farnsworth Munsell test. The patient is presented with small
color plates that he must select and sort according to a fixed blue color marker. The patient with color vision defect will confuse markers.
• 100 HUEtest – 100 plates which should be placed in propter sequence
according to the colors of the rainbow in the right order.
• Anomaloscope – it is a quantitative evaluation. The most accurate instrument
for classifying color defect. There is a split screen and we ask the patient to view the screen. There are two halves and the patient tries to match both halves by mixing varying proportions of red and green or green and blue colors.The final adjustment allows to calculate the anomaly ratio.
b. Visual field examination (perimetry): The visual field is defined as the field of perception of the eye at the rest with the gaze directed straight ahead. It includes all points in space that are simultaneously visible when the eye focuses on one point. Only one eye is examined at a time. Light markers appear in the hemisphere of the device. The patient signals that he or she perceives the marker by pressing a button that triggers an acoustic signal. \ Blind spot is represented by an absolute scotoma corresponding to the scleral canal through which the retinal nerve fibres leave the canal at the optic disk. Isopter – is a line drawn in a visual field chart which connects all points which have this same sensitivity in the retina. There are two types of perimetry – kinetic involves moving points of light that travel into the hemisphere. The patient is asked to signal when he notice the marker and indicate when it disappears and again when it reappears. Static perimetry (computerized involves the static light markers and their intensity increases until there are perceived. Scotoma is a depression of sensitivity surrounded by areas of relatively well preserved function of retina. Relative scotomas – when some visual sensation remains and absolute scotomas when there is no visual sensation and no matter how bright is the stimulus. Scotomas are classified by location,(central, paracentral) size, shape (round,sectoral,arcuate). Indications:
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