5- AH Eye PD lec 2023.pptx

1 Physical Diagnosis: EYE DR. AHMAD HALIMI, DMSC, PA-C, CAQ-HM EMAIL: [email protected] 2  Upper eyelid covers portion of iris but not the pupil  Palpebral fissure = opening between the eyelids  Conjunctiva is clear mucous membrane  Bulbar conjunctiva covers most of anterior eyeba...

1 Physical Diagnosis: EYE DR. AHMAD HALIMI, DMSC, PA-C, CAQ-HM EMAIL: [email protected] 2  Upper eyelid covers portion of iris but not the pupil  Palpebral fissure = opening between the eyelids  Conjunctiva is clear mucous membrane  Bulbar conjunctiva covers most of anterior eyeball and adheres loosely to underlying tissue  Meets cornea at limbus 2 3  Palpebral conjunctiva  Lines the eyelids   Two parts meet in a folded recess permitting movement of eyeball Tarsal plates  Firm strips of Connective Tissue  Each plate contains parallel row of meibomian glands which open on lid margins- produces meibum to prevent evaporation of eyes tear film 3 4  Levator palpebrae  Muscle raises upper lid Levator palprbrae  Innervated by  Oculomotor CN III  Smooth muscle innervated by sympathetic NS also contributes to lid elevation  Tear fluid  Protects conjunctiva  Inhibits bacterial growth  Gives smooth surface 4 5  Cornea  Clear layer at front and center of eye  Lies in front of the iris  Function: helps focus light as it enters the eye  Sclera  White outer coat of eye  Tough, leather like tissue extends around the eye  Gives the eye its 5 6  Choroi  Layer of blood d vessels between retina and sclera  Iris  Colored part of eye which helps regulate amount of light entering the eye by opening and closing the pupil (acts like shutter 6 7  Len s  Transparent, crytalline  Focuses light on the retina  “fine tunes” vision  Deterioration with ageing leads to farsightedness  Intraocular lenses 7 8  Optic nerve  Over a million nerve fibers carrying messages from the retina to the brain  Retina  Nerve layer lining the back of the eye  Senses light and creates electrical impulses sent through the optic nerve to the brain 9  Lacrimal gland  Lies mostly within bony orbit & lateral to eyeball  Tears drain medially through two tiny holes called lacrimal puncta  Located on lower lid medially  Tears then pass into lacrimal sac and into nose thru 10  Eyeball = Sphericle  Focuses light on the retina  Pupilary size  controlled by muscles of the iris  Thickness of the LENS  controlled Ciliary Body by the 11 Aqueous humor Clear liquid   Produced by ciliary body  Fills anterior and posterior chambers of eye  Circulates from posterior chamber thru the pupil to the anterior chamber  Drains out of the anterior chamber thru the canal of schlemm  This circulatory system controls pressure inside the eye ! Circulation of Aqueous humor  Posterior eye = FUNDUS  Seen with ophthalmoscope  Structures of the fundus  Retina  Choroid  Fovea  Macula  Optic disc  Retinal vessels  Optic nerve and retinal vessels 12 13  Macula  Point of central vision  Lateral and slightly inferior to optic disc  Small depression in retina  Fovea  Small dark circular area circumscribed by the macula  Vitreous body  Transparent gelatinous material that fills the eyeball behind the lens 14  Optic disc  Intraocular portion of the optic nerve  Its margins, color and cup to disc ratio should be determined  It has sharp borders, yellow-orange to creamy pink  Round to slightly oval with its long axis 15  Physiologic  Small depression in the center of the optic disc cup  The cup is the portion of the disc which is central, lighter in color and penetrated by the retinal vessels  Horizontal diameter < ½ the horizontal diameter of the disc  Cup to disc ratio is expressed as a decimal  1 6 Macula and Fovea  Area of the retinal responsible for fine central vision  Darker grey appearance  Oval depression in center of macula is called a fovea  The FOVEA = the center of the retina.  Asking the patient to look directly into the light of the ophthalmoscope will bring the fovea into your 16 17 Arteries and veins   Visible with ophthalmoscope  Central retinal artery branches at the optic disc into divisions that supply the 4 quadrants of the inner retinal layers  Veins form a similar pattern to the arteries * Arteries are SMALLER in diameter than the veins 18  Visual  Entire area seen by an eye when it looks at a central fields point  Center of circle = focus of gaze  Each visual field is divided into quadrants  Fields extend farthest on the temporal sides  Fields restricted by, eyebrows, cheeks, and nose  Blind spot: = lack of retinal receptors at optic disc  Located 15º temporal to the line of gaze 19 An enlarged BLIND SPOT occurs in conditions that affect the optic nerve such as GLAUCOMA, PAPILLEDEMA and OPTIC NEURITIS 20  When using both eyes  The two visual fields overlap in an area of binocular vision  Laterally vision is monocular  Visual pathways  Light reflected from the image MUST pass thru the pupil to be focused on sensory neurons in the retina  Image projected is upside down and reversed R to L  ie: an image from the upper 2 1  Visual pathways  Nerve impulses stimulated by light  Are conducted thru the retina, optic nerve and optic tract on each side  then to the optic radiation that ends in the visual cortex of the brain in the occipital lobe http://www.edoctoronline.com/medical-atlas.asp?c=4&id=21964&m=1&p=7&cid 2 22  Pupillary reaction  Pupillary size changes in response to light and effort of focusing on a near object  The Light reaction  Direct Light shining onto retina  Consensual  Opposite eye response  23  IN CN II (afferent limb)  Light enters optic disc and then photosensitive retinal ganglia cells pass info to the optic nerve CN II In the midbrain impulses to the the Edinger-Westphal nucleus, whose parasympathetic axons run along both the left and right oculomotor nerve cause pupillary constrictioin  OUT CN III (efferent limb)  Motor   The Near Reaction  Pupils constrict when shifting gaze from a far object to a near object  Reaction innervated by the Ocumomotor CN III similar to the pupillary reaction  Convergence  also occurs This is an extraocular movement  Accomodation  also occurs Increased convexity of the lenses caused by contraction of the ciliary muscles (this is difficult to actually see or 2 4 2 5 Autonomic Nerve supply to eyes   Fibers travelling to the oculomotor nerve and producing pupillary constriction are part of Parasympathetic NS  Iris is supplied by the sympathetic NS  When stimulated, the pupils dilate and upper lid rises a little  This pathway starts in the hypothalmus thru the brainstem and cervical cord 5 26  Extraocular movements  Movement of each eye is coordinated by 6 muscles  4 rectus and 2 oblique muscles  There are 6 cardinal directions  All CN III except LR VI(abducens) and SO 27 Extraocular muscles LR6 SO4 - R3 LR6 SO4 R3 Latera l Rectu s Superi or Obliqu e Remaini ng eyeball VI abducens IV trochlear III oculomotor 28  Visual disturbances  Spots (scotomas)  Flashing lights  Use of corrective lenses  Trauma  Pain  Redness  Excessive tearing  Double vision(diplopia) or Blurry vision  2 Seeing two different images on the same 9  Is it monocular or binocular object   Have the patient cover one eye…. If they still see double.. It is monocular  Monocular double vision isn’t a neurologic problem at all and your exam just got easier!  It is usually a refractive problem in the front of the eye  Most common cause is astigmatism = abnormal curvature of the corneal surface Binocular diplopia  Occurs when the eyes do not move in synchrony with each other  CN lesions (CN3, CN4, CN6), EOM abnormalities (muscle fibrosis seen in Grave’s disease) 30  The retina separates from the layer underneath. Symptoms include an increase in the number of floaters, flashes of light, and worsening of the outer part of the visual field. This may be described as a curtain over part of the field of vision. In about 7% of cases both eyes are affected. Without treatment permanent loss of vision may occur. Some risk factors are glaucoma, HX of cataract surgery, diabetic retinopathy, and family Hx of retinal detachment. 31  Ptosi s Entropion  Ectropion  Lid retraction and exopthalmus   Xanthelasma Dacrocyysitis/ stenosis  Conjunctivitis  Subconjunctival hemorrhage  Pinguecula  Corneal Arcus  Sty/ Hordeolum  Pterygium  Chalazion   Episcleritis  Cataracts Periorbital cellulitis 32  Drooping of the upper lid  Causes include:  Myasthenia Gravis  Damage to the oculomotor nerve  Damage to the sympathetic nerve supply (Horner's syndrome).  A weakened muscle, relaxed tissues, and the weight of herniated fat may cause senile ptosis 33  Inward turning lid margin  More common elderly   Outward turning lid margin exposing palpebral conjunctiva  If punctum of lower lid turns outward, eye drainage is affected  More common elderly Lashes irritate cornea 34  Can see rim of sclera between upper lid and iris stare suggests this disorder  Wide-eyed   Association with lid lag suggests hyperthyroidism Exophthalmus  Eye protrudes forward  Bilateral suggests infiltrative opthalmopathy of Graves’ Disease  May have associated edema of eyelids and conjunctival injection 35     Benign yellowish triangular nodule in bulbar conjunctiva on either side Frequently seen with aging Often first seen on nasal side Does not interfere with vision     Triangular thickening bulbar conjunctiva grows slowly across outer surface of cornea Usually on nasal side Reddening may occur Can encroach upon pupil and interfere with vision 36  Blood in the anterior chamber  Pus (WBC infiltration) in the anterior chamber 37    Inflammation of the episcleral vessels that appear salmon pink Localized ocular redness May be nodular  Slightly raised yellowish wellcircumscribed plaques  Appear along nasal portion one or both lids  May accompany lipid disorder 38  painful, tender red infection in a gland at the margin of the eyelid   subacute nontender and usually painless nodule involving a meibomian gland. May become acutely inflamed but, unlike a sty, usually points inside the lid rather than on the lid margin 39   Swelling between the lower eyelid and nose Acute inflammation (illustrated) is painful, red, and tender  Chronic inflammation: associated with obstruction of the nasolacrimal duct  Tearing is prominent  Pressure on the sac produces regurgitation of 40   Diffuse dilatation of conjunctival vessels with redness that tends to be maximal peripherally No affect on vision or pupil  Watery, mucoid or mucopulrulent discharge  Bacterial, viral, parastic, irritation, or allergic 41  Leakage of blood outside of the vessels, producing a homogeneous, sharply demarcated, red area that fades over days to yellow and then disappears  Not painful  No affect on vision, pupil or cornea  Resolves spontaneously 42 Inflammation and infection of the eyelid and portions of skin around the eye anterior to the orbital septum.  It may be caused by breaks in the skin around the eye, and subsequent spread to the eyelid; infection of the sinuses around the nose (sinusitis); or from spread of an infection elsewhere through the blood   Staph-aureus ,Streppneumo, and other streptococci are most common causes 43 Ciliary  injection dilation of deeper vessels that are  visible as radiating vessels or a reddish violet flush around the limbus  Imp’t sign in 3 conditions:  Injury/infection  Acute iritis  Glaucoma THE RED EYE Pattern of redness Pain Vision Ocular discharge Pupil Cornea l infecti on Injury Mod/severe Usu decreased Watery/purulent Not affected Cornea Depends on cause Significance Abrasians, viral, bacterial Acute Iritits Mod/achy/deep Decreased Absent Small/irreg with time Clear/ slightly clouded Associated with systemic ocular 44 Glaucoma Severe/achy/deep Decreased absent Dilated, fixed Steamy, cloudy Acute increase IOP – an emergency! 45   Thin grayish white arc or circle not quite at the edge of the cornea Accompanies normal aging  Also seen in younger people, especially AfricanAmericans  In young people, suggests possible hyperlipoproteinemia  46   Opacities of the lenses visible through the pupil Most common in old age  Can be nuclear (central) or peripheral Nuclear Peripheral 47  Superficial grayish white opacity in the cornea, secondary to an old injury or to inflammation  Size and shape are variable  It should not be confused with the opaque lens of a cataract which is visible on a deeper plane and only through the pupil. 48 http://en.wikipedia.org/wiki/Lens_(vision)   Progressively diminished ability to focus on near objects with age Etiology  Loss of elasticity of the crystalline lens  Changes in the lens's curvature from continual growth  Loss of power of the ciliary muscles (the muscles that bend and straighten the lens) have also been postulated as its cause  MYOPIA = impaired far vision 4 9  Tonic pupil (Adie’s pupil) Oculomotor CN III Paralysis  Horner’s syndrome  Small irregular pupils  Blind eye  Marcus Gunn Pupil  Argyll Robinson Pupil   Seen in Syphilis 49  A difference in the size of two pupils > 4mm  Present in 1/5 of the population May be normal or a sign of ocular or neurologic disease   Should be considered a neurosurgical emergency if a patient has anisocoria with acute onset of third-nerve palsy and associated with headache or trauma  Symmetrically rapid constriction in pupillary light response indicates that the anisocoria is not due to third-nerve palsy  If the difference in pupil size in both light and dark illumination is constant, then it is called 50 51     Large, irregular Usually unilateral Slowed or absent reaction to light Slowed accommodation causes blurred vision Image from http://www.atlasophthalmology.com/at las/photo.jsf?node=5832&locale=en   Dilated pupil (67mm) is fixed to light and near reaction May have associated ptosis and lateral eye deviation right pupil is non-reactive; complete ptosis, hypoexotropia, impaired adduction, elevation and depression in the right eye. Image from http://www.atlasophthalmology.com/atlas/photo.jsf?node= 5830&locale=en     Damage to SNS Small pupil (miosis) that reacts to light and acommodation (^ with dim lighting) Ptosis present Loss of sweating on forhead anhydrosis 52  Small, irregular pupil: accomodates but do NOT react to light  Seen in tertiary syphilis 13-year-old female patient with congenital Horner’s syndrome. Prominent ptosis, miosis, and iris hypopigmentation of the left eye http://www.ajnr.org/cgi/content/full/23/6/929/F1 5 http://www.youtube.com/watch?v=HSYo7L hfV3A 53   Relative Afferent Pupillary Defect(RAPD) indicating a decreased pupillary response to light in the affected eye Most common cause is lesion of optic nerve (distal to the optic chiasm) or severe retinal disease 54    Caused by imbalance in ocular muscle tone Often hereditary Causes gaze deviation classified according to direction  ESOTROPIA – eye deviated medially  EXOTROPIA - eye deviated laterally  Can do cover-uncover 55  New onset dysconjugate gaze  Etiology  Nerve injury  Lesions, trauma, MS, syphilis and others 56  Fine, rhythmic oscillation of the eye  Vertical, horizontal or rotatory  Few beats on extreme gaze is normal 57   Physiologi c cupping (a) Temporal cup a (b)  Rings and crescents (c)  Medulated nerve fibers (d) b c d 58 59           Papilledem a Glaucomatous cupping Optic atrophy AV nicking Cotton wool patches Flame shaped hemorrhages Microaneurysms Hard exudates Diabetic retinopathy Hypertensive retinopathy  Papilledema  Venous stasis leads to engorgement and swelling  Disc swollen with margins blurred  Physiologic cup not visible  Glaucomatous cupping  Backward depression of disc & atrophy  Base of enlarged cup is pale  Physiologic cup > 0.5  Optic atrophy 60 61  AV nicking  Cotton wool patches (soft exudate)  Flame shaped hemorrhages and deep retinal hemorrhages  Microaneurysms  Hard exudates  Papilledema 62  Vein appears to stop abruptly on either side of the artery    White or greyish, ovoid lesions with irregular “soft” borders Usually smaller in size than the disc Results from infarcted nerve fibers  Superficial  Small, linear, flame-shaped red streaks in the fundi  Seen in severe HTN, papilledema, retinal vein occlusion  Deep  Small, rounded, slightly irregular red spots  Occur in deep retinal layers  Seen in diabetes  Preretinal  Blood in potential space between retina and 63  Tiny, round, red spots often near macular  Minute dilitations of very small retinal vessels  Seen in diabetes +  Formation of new blood vessels  More 64 numerous and tortous and narrower than other blood vessels  Seen in late proliferative stage of DM retinopathy  Vessels can grow into vitreous and cause retinal detachment or visual loss 65  Creamy or yellowish, often bright lesions with well-defined hard borders  Small and round and amy coaelsce  Seen in DM and HTN  Small, tiny yellow, round spots  Appear in normal aging  May accompany age- related macular degeneration 66  Nat’l standard  Nonproliferative, moderately severe  Nonproliferative, severe  Proliferative retinopathy with neovascularizati on  Proliferativ e 67  Increased light reflex from arteries: copper wiring  Venous tapering at the AV crossing – AV nicking  Exudates  Soft exudates: cotton wool patches  Hard exudates  Flame shaped hemorrhages 6 8 Bates 6 9 Bates page 265  7 0 Swelling of the optic disc due to increased intracranial pressure  Unilateral or bilateral  Assymptomatic or  Headache, blurry vision, partial or total loss of vision, enalrgement of blind spot  Paton's lines = radial retinal lines cascading from the optic disc http://faculty.washington.edu/alexbert/M70EDEX/Fall/HEENT_PE_Obj.htm 7 1  On fundoscopic exam  Venous engorgement (usually the first signs)  Loss of venous pulsation  Hemorrhages over and / or adjacent to the optic disc  Blurring margins of optic 72   Leading cause of blindness in Western countries Loss of central vision   “dry” and “wet” forms   Choroid lies behind retina and contains blood supply to macula Either debris(drusen - dry) or blood vessels (wet) form between retinal and choroid leading to retinal detachment Risk factors  Increasing age >50  Current smoking   Previous Family cataract www.vrmny.com/pe/amd/dmd.html www.clevelandsightcenter.org/resources /conditions/images/wet_macular_fundus http://www.medscape.com/viewa72rticle/735166_6 73  Changes in vision  Cataracts  Clouding of the lens  Macular degeneration (MD)  Mottling, retinal pigmentation, retinal exudate/hemorrhage  Glaucoma   Change in size optic cup Disorders of vision shift with age  Healthy  Over young people: refractive errors 65: cataracts, MD, and Glaucoma > common 74   Leading cause blindness in African Americans Second leading cause of blindness overall  Gradual loss of vision with damage to the optic nerve  Loss of visual fields (periphery 1st)  Pallor and increasing size optic cup (>0.5)  Elevated  intraocular pressure (IOP) Risk factors  Age>65, DM, FH, myopia, ocular HTN 75   A refractive defect of the eye – Distant objects appear blurry Collimated light produces image focus in front of the retina when accomodation is relaxed 76  Either eyeball is too short or lens cannot become round enough  You can see distant objects clearly ,but nearby objects may be blurry  Image not focused on the retina  This is NOT the same as presbyopia which is lack of the ability of the lens to 77  Equipment  Needed Pocket vision chart  Ophthalmoscope  Inspection  Visual Acuity   Corneal Reflections Pupillary Reactions  Light and  Visual Fields  Extraocular Movements  Convergence  Ophthalmoscopic Exam  Special Tests  Upper Eyelid Eversion 78  Position and alignment of eyes  Eyebrows quantity, distribution   Lacrimal apparatus  Lacrimal gland and sac for swelling  Conjunctiva and sclera Eyelids   Width of palpebral fissures Edema, color, lesions  Condition and  direction of   Color, vascular pattern Cornea and lens  opacities   Iris – markings clearly defined Pupils – size,  You may note “scaliness” of eyebrows in seborrheic dermatitis or lateral “sparseness” of eyebrows in hypothyroidism 79 80  Have patient look up and depress both lower lids with yourpattern, thumbs  Note color, vascular nodules or swelling 81  Corneal Arcus  Cataract  Pterygium  Scarring 82  Shine light on temporal  Because iris is usually flat there should side be NO shadow  A crescent shadow suggests a narrow angle due to bowing of the iris  This increases the risk of acute narrowangle glaucoma 83   Central vision: Snellen eye chart; position patient 20 feet from the chart Patients should wear glasses if needed  Test one eye at a time  Near vision:   hand-held card (can also use to test visual acuity at the bedside) hold 14 inches from patient’s eyes 84 Defined in US as visual acuity of 20/200 or worse in the best seeing eye OR A visual field of 20º or less 85  Vision of 20/200 means that at 20 feet the patient can read print that a patient with normal vision can read at 200 feet. The larger the second number, the worse the vision is. “ 20 /40 corrected” means that a patient could read the 40 line with glasses/contacts ( a correction) 86     Size, shape, symmetry  Round, 3-5mm Direct  Pupil constriction same eye Consensual  Pupil constriction opposite eye Equal pupils and one blind eye with normal Neuro  Blind eye has consensual light reflex, Miosis: constriction 87  Screenin  g Both eyes at same time; start in the temporal fields because most defects are here  Further testing  If a defect is found, test one eye at a time 88  6 cardinal directions of  gaze Make wide “H”  Observe for  Normal conjugate movements  Nystagmus  Lid lag  Convergence Abducens CN6 palsy CN3 palsy Ptosis and mydriasis www.ophthobook.com/chapters/neuroophthalmology 89   Have patient follow your finger or pencil as you move it in toward the bridge of the nose The converging eyes normally follow the object to within 5-8cm of the nose  Covergence may be poor in 90   Lid lags as eye moves from up to down Seen in hyperthyroidis m A rim of sclera is visible with downward gaze “setting sun” sign in hydrocephalus www.ispub.com/.../ijtwm/vol3n1/s pina.xml 91  Used to determine if ocular alignment is normal  Ie: a temporal light reflection on the cornea suggests a nasal deviation of that eye 92 93  Assessing protruding eyes (proptosis/exophthalmus)  Can test for lid lad or lack of convergence  Nasolacrimal duct obstruction  Upper palpebral conjunctiva  Flipping the Upper lid 94  Exophthalm os  Stand behind seated patient  Inspect from above  Exophthalmeter measures distance between lateral angle of the orbit and imaginary line across most anterior part of cornea  < 20mm white americans, <22 in african americans 95 96   Have patient look up Press on lower lid close to medial canthus  This compresses the lacrimal sac  Observe for fluid regurgitating out of the puncta into the eye  NOTE: AVOID this test is area is inflamed or irritated!   Should be done to R/O foreign body Have patient look down  Grasp upper eyelashes and pull them gently down and forward  Place cotton swab stick or tongue blade 1cm above lid margin  Push down on stick as you raise the edge of the lid turning it “ inside out”  Avoid pressing on eyeball itself  Secure upper lashes against eyebrow to observe  Grasp upper lashes, pull gently forward and 97 98 99  Darken the room and have the patient look off in the distance Switch the ophthalmoscope light and turn the lens disc to the large round beam of white light  Turn lens disc to the 0 diopter  Hold the ophthalmoscope in your right hand to examine the patient’s right eye with your right eye; hold it in your left hand to examine the patient’s left eye with your left eye  Stand directly in front of the patient, 15 inches away, and start at an angle of 15 degrees lateral to the patient’s line of vision  Shine the beam of light onto the pupil and look for an  100  Come in at 15-30ºangle  Observe red light reflex  Move diopters to focus on optic disc: dis:cup ratio< o.5  Note vessels and inspect from disc outward in 4 directions  Have patient look into light to observe macula 10 101  An opacity of the lens (cataract)  Opacity of the vitreous  Detached retina (less common)  In children, a retinoblastoma  (of course the eye could be artificial – don’t be fooled) www.retinoblastoma.com/retinoblastoma/guide3.htm www.chect.org.uk/page.php?id=71&a1i0d1 =277&s=6 102  Pupillary reflex: CN II & CN III  Extraocular movements  Oculomotor CN III  Trochlear CN IV  Abducens CN VI  Majority ocular muscles are innervated by CN III  Also the levator palpebrae which raises the lid (observe for ptosis)  Parasympathetic pupillary constrictors also run along CNIII   Superior oblique: CN IV Lateral rectus: CN VI 10 3  PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive to Light and Accommodation.  The use of this term is so routine that it is often used incorrectly. If you did not specifically check the accommodation reaction use the term PERRL  Diopters are used to measure the power of a lens The ophthalmoscope actually has a series of small lens of different strengths on a wheel (positive diopters are labeled in green, negative in red)   When you focus on the retina you "dial-in" 10 the http://www.rxlist.com/eye_diseases_slideshow/article.htm 104   Eyes: visual acuity 20/20 individually and bilaterally uncorrected. There is no ptosis, inflammation or lesions of the lids  Visual fields by confrontation are intact  Sclera white, conjunctiva clear  Pupils 4mm equal, round and reactive to light and accommodation. (PERRLA)  Extraocular movements are intact (EOMI)  Positive red reflex, disc margins sharp, disc:cup ratio < 0.5, no arteriolar narrowing, AV nicking, 10 105  https://youtu.be/0ggAMBXi1 J0 10