Ophthalmologic Exam PKM 2023.pdf

The Ophthalmologic Examination Pat Kenney-Moore EdD, PA-C OHSU PA Program Summer 2023 The Ophthalmologic Examination  "Of all the organs of the body, the eye is most accessible to direct examination. Visual function can be quantified by simple subjective testing. The external anatomy of the eye is...

The Ophthalmologic Examination Pat Kenney-Moore EdD, PA-C OHSU PA Program Summer 2023 The Ophthalmologic Examination  "Of all the organs of the body, the eye is most accessible to direct examination. Visual function can be quantified by simple subjective testing. The external anatomy of the eye is visible to inspection with the unaided eye and with fairly simple instruments. Even the interior of the eye is visible through the clear cornea. The eye is the only part of the body where blood vessels and central nervous system tissue (retina and optic nerve) can be viewed directly. Important systemic effects of infectious, autoimmune, neoplastic, and vascular diseases may be visible from the internal eye examination...." Vaughan & Asbury's General Ophthalmology, 16th Ed. Assessment of Visual Acuity – The Vital Sign of the Eye Snellen chart read at 20' – assesses distance vision Rosenbaum chart read at 10-14” – assesses near vision Assessment of Visual Acuity  Visual Acuity - recorded as a fraction  X/Y = The distance at which the patient can see…vs. the distance at which a normally sighted individual can see  20/20 = the pt can see at 20 ft. what a normally sighted person can see at 20 ft. In this case, they are the same  20/200= the patient can see at 20 ft. what a normally sighted person can see at 200 ft The is 20 What you can see at that I Bottom is what the pt sees m at 20 feet Assessment of Visual Acuity Legal blindness = 20/200 Complete blindness = NLP (no light perception) VA typically recorded with correction using the following abbreviations: OD – oculus dexter OS – oculus sinister OU – oculus uterque Both eyes If correction unavailable, try the pinhole technique Assessment of Visual Acuity  Emmetropia – Normal vision The condition of the normal eye when parallel rays are focused exactly on the retina and vision is perfect  Presbyopia – Aging vision The lens of the eye loses its ability to focus The condition is associated with aging and is progressive People who have presbyopia have difficulty seeing objects close-up Assessment of Visual Acuity of the If The visual image is focused behind the retina rather  Hyperopia – Farsightedness Feb than directly on it  It may be caused by the eyeball being small or the focusing power being weak  A farsighted person sees faraway objects clearly, while objects that are near are blurred  Myopia – Nearsightedness The visual image is focused in front of the retina, rather than directly on it  Occurs when the physical length of the eye is greater than the optical length  A nearsighted person sees near objects clearly, while objects in the distance are blurred Correction of Near/Farsightedness Peripheral Vision  Assess visual fields by confrontation – check patient’s peripheral vision by comparing with the examiner’s while sitting across from each other  Test each eye separately  Test nasal and temporal sides separately  Screening shortcut with finger addition exercises Visual Pathways Anatomy of the Eye External Anatomy Physical Examination of the External Eye  Inspect area around external eye - adnexa  Palpate over lacrimal gland  Inspect sclera and conjunctiva overlying  Assess with ambient light and penlight  Assess anterior chamber depth with a penlight from the side Anatomy – Lacrimal Apparatus  Tears produced in lacrimal gland  Wash over eye and drain into puncta  Drain into lacrimal sac into nasolacrimal duct Anterior Chamber Depth Pupillary Reaction Pupillary Reaction Look at pupil size and shape bilaterally before using a light Bring light in from the patient’s side Protect other eye from light – create a light dam Assess for direct pupillary reaction as well as consensual Record as PERRLA – what is the “A” for? Accomodation Extraocular Movements (EOMS)  LR6SO4 All the rest CNIII  Move through cardinal direction and evaluate for conjugate gaze, nystagmus and lid lag  Normal is documented as EOMI Assessment of Strabismus  Strabismus is the condition where the eyes are misaligned the problem may be present intermittently or continuously  Inward crossed eyes (esotropia, the most common type in children “crossed eye”)  out-turned eyes (exotropia – “wall eye”)  vertical misalignment (hyper or hypotropia) Strabismus Terminology  Assess by determining corneal light reflex, coveruncover test and directionality of eye orientation Check your skills Ophthalmoscopy  Dilated vs. undilated exam  Ambient light  Right hand, right eye, right eye  Left hand, left eye, left eye  Remove your glasses – keep your contacts in Filters Red free filter Polarizing filter Apertures Ophthalmoscopy Technique Hand on patient’s head – lift brow Locate red reflex by looking through device Move in close to patient (If you are not close enough to be uncomfortable, you’re not close enough!) Focus on anything on the retina Slowly move to optic disc/cup, follow retinal arteries & veins, look at 4 quadrants and macula Practice! Making Sense of Diopters  The optic disc should come into view when you are about 1.5 to 2 inches (3-5cm) from the patient at a 10-15° angle from the midline  If it is not focused clearly, rotate lens dial slowly using your index finger until the optic disc or other structure is as clearly visible as possible  The hyperopic, or far-sighted, eye requires more “plus” (black numbers) for clear focus; the myopic, or nearsighted, eye requires “minus” (red numbers) for clear focus  +10 to +20 to see the iris Retinal Examination Documentation of the Retinal Exam Include mention of: Presence or absence of red reflex Color of disc & crispness of disc margins Cup to disc ratio ( ie. cd