Orientation, history Orientation, history taking, and examinationtaking, and examination

byby

Hani Al-MezaineHani Al-MezaineAssociate ProfessorAssociate ProfessorCollege Of MedicineCollege Of MedicineKing Saud UniversityKing Saud University

OrientationOrientationCourse OPH 432Course OPH 432

Objectives Objectives a. To know the basic ophthalmic anatomy and a. To know the basic ophthalmic anatomy and

physiology. physiology.

b. To recognize assessment and management of b. To recognize assessment and management of common ophthalmic diseases. common ophthalmic diseases.

c. To know how to handle common ophthalmic c. To know how to handle common ophthalmic emergencies. emergencies.

d. To handle simple ophthalmic diagnostic d. To handle simple ophthalmic diagnostic instruments. instruments.

e. To be aware of common ophthalmic operations.e. To be aware of common ophthalmic operations.

Components of the courseComponents of the course

• LecturesLectures

• ClinicsClinics

• OROR

• Clinical sessionsClinical sessions

• ERER

LecturesLectures

1.1. History taking and physical examination History taking and physical examination in ophthalmology in ophthalmology

2.2. Basic Anatomy and Physiology of the EyeBasic Anatomy and Physiology of the Eye

3.3. Lid, Lacrimal, and Orbit DisordersLid, Lacrimal, and Orbit Disorders

4.4. Ocular emergencies and red eyeOcular emergencies and red eye

5.5. Strabismus, Amblyopia and LeukocoriaStrabismus, Amblyopia and Leukocoria

6.6. Acute Visual LossAcute Visual Loss

7.7.Chronic Visual LossChronic Visual Loss

8.8.Refractive ErrorsRefractive Errors

9.9.Ocular manifestations of systemic Ocular manifestations of systemic diseasesdiseases

10.10.Neuro-ophthalmologyNeuro-ophthalmology

11.11.Ocular Pharmacology and Ocular Pharmacology and ToxicologyToxicology

Clinical skill sessions Clinical skill sessions

1.1.External Ocular Examination, Ocular External Ocular Examination, Ocular motality and Alignmentmotality and Alignment

2.2.Visual acuity and OphthalmoscopyVisual acuity and Ophthalmoscopy

3.3.Visual field, Tonometry, Pupill Visual field, Tonometry, Pupill ExaminationExamination

Marks distributionMarks distribution

• 3535 marks for marks for the MCQs the MCQs

• 60 marks for the OSCE60 marks for the OSCE

• 5 5 marks for attendance in clinical marks for attendance in clinical sessions, clinics, ER, OR.sessions, clinics, ER, OR.

Recommended textbooksRecommended textbooks1. Required Text(s) 1. Required Text(s)

a. a. Lecture notes OphthalmologyLecture notes Ophthalmology (latest edition) (latest edition)

By: Bruce James (published by Blackwell Science)By: Bruce James (published by Blackwell Science)

b. Basic Ophthalmology b. Basic Ophthalmology (latest edition)(latest edition)

By: Cynthia A. Bradford (latest edition) By: Cynthia A. Bradford (latest edition)

(published by American Academy of (published by American Academy of Ophthalmology)Ophthalmology)

c. Practical Ophthalmology: A manual for Beginning c. Practical Ophthalmology: A manual for Beginning Residents Residents (latest edition)(latest edition)

By: Fred M. Wilson (published by American Academy of By: Fred M. Wilson (published by American Academy of Ophthalmology Ophthalmology

2. References2. References

• Vaughan and Asbury’s general OphthalmologyVaughan and Asbury’s general Ophthalmology

By: Paul Riordan-Eva (published by LANGE)By: Paul Riordan-Eva (published by LANGE)

• Clinical Ophthalmology: A Systematic ApproachClinical Ophthalmology: A Systematic Approach

By : Jack T. Kanski (published by Butterworth By : Jack T. Kanski (published by Butterworth Heinemann)Heinemann)

c. Electronic Materials, Web Sites c. Electronic Materials, Web Sites

1. Department internet website. 1. Department internet website.

2. Department’s teaching staff personal websites on 2. Department’s teaching staff personal websites on University site. University site.

3. University and KKUH/KAUH Library. 3. University and KKUH/KAUH Library.

4. Audiovisual Unit of the Ophthalmology 4. Audiovisual Unit of the Ophthalmology Department. Department.

5. PubMed 5. PubMed

5. Medscape5. Medscape

6. The digital journal of ophthalmology 6. The digital journal of ophthalmology (www.djo.harvard.edu)(www.djo.harvard.edu)

Why should you be interested in the eye?

If there is a barrier between the examiner and If there is a barrier between the examiner and the patient – a barrier with an opening of the patient – a barrier with an opening of 1 square inch through which the 1 square inch through which the examination can be performed.examination can be performed.

Which square inch you will choose??!! Which square inch you will choose??!!

Diagnostically and functionally, it is Diagnostically and functionally, it is the most important the most important square inch square inch of of the body surface.the body surface.

Of all the organs of the body, the eye is Of all the organs of the body, the eye is most accessible to direct examination.most accessible to direct examination.

The external anatomy of the eye is The external anatomy of the eye is visible to inspection with unaided eye visible to inspection with unaided eye and with fairly simple instruments.and with fairly simple instruments.

The health or disease of a large portion The health or disease of a large portion of the body can be determined simply by of the body can be determined simply by looking at the eye.looking at the eye.

• The eye is so intimately connected The eye is so intimately connected with the rest of the body that it reveals with the rest of the body that it reveals enormous amount of general enormous amount of general information.information.

• Eye is the only part of the body where Eye is the only part of the body where blood vessels and central nervous blood vessels and central nervous system tissues can be viewed directly.system tissues can be viewed directly.

ExamplesExamples

Neurological Neurological connectionsconnections

• The 12 cranial nerves provide us with a The 12 cranial nerves provide us with a large part of our information about the large part of our information about the brain. Of these , the eye examination brain. Of these , the eye examination evaluates CN II, III, IV, V, VI, VII, VIII. evaluates CN II, III, IV, V, VI, VII, VIII.

• In addition, it provides information In addition, it provides information about the autonomic pathways.about the autonomic pathways. (sympathetic /parasympathetic)(sympathetic /parasympathetic)

The best known connection between the The best known connection between the brain and the eye is the ON.brain and the eye is the ON.

The visual pathways, which extends from The visual pathways, which extends from front to back across the brain can be front to back across the brain can be studied easily and safely using perimetry. studied easily and safely using perimetry. It can differentiates accurately between It can differentiates accurately between lesions of the temporal, parietal, and lesions of the temporal, parietal, and occipital lobes.occipital lobes.

• In addition, the ON has important In addition, the ON has important clinical relationships to the pituitary clinical relationships to the pituitary gland, the middle ventricles, the gland, the middle ventricles, the venous sinuses, the meningeal and venous sinuses, the meningeal and bony structures of base of the skull.bony structures of base of the skull.

ON has the diagnostically ON has the diagnostically useful capability of swelling useful capability of swelling with with ↑ ↑ ICP (ICP (papilledemapapilledema).).

Or Or

visibly pale (visibly pale (optic atrophyoptic atrophy) ) when its nerve fibers when its nerve fibers damaged at any point from damaged at any point from Retina Retina → → LGB.LGB.

The study of The study of CN III, IV, V, VI CN III, IV, V, VI can evaluates can evaluates the brain stem , the brain stem , cavernous sinus, cavernous sinus, apex of orbit .apex of orbit .

Unilateral dilated pupil after head Unilateral dilated pupil after head injury can occur due to pressure on injury can occur due to pressure on pupil constrictor fibers of CN III.pupil constrictor fibers of CN III.

CN VI involved in mastoid infection CN VI involved in mastoid infection (petrous ridge)(petrous ridge)

Parotid gland, Inner ear disease Parotid gland, Inner ear disease → → CNCN VII.VII.

Nystagmus Nystagmus → → CN VIIICN VIII

Focal brain lesions like:Focal brain lesions like:

Vascular occlusions Vascular occlusions

Hemorrhage Hemorrhage

NeoplasmNeoplasm

Diffuse brain lesions like: Diffuse brain lesions like:

Infections Infections

Demyelinating disorders Demyelinating disorders → → nerve damage.nerve damage.

Vascular connectionsVascular connections

Venous flow disorder: Venous flow disorder:

cavernous sinus cavernous sinus thrombosis, thrombosis,

carotid – cavernous carotid – cavernous fistula fistula

(orbital congestion)(orbital congestion)

Arterial emboli can reach the retina Arterial emboli can reach the retina from carotid artery , heart valves, from carotid artery , heart valves, subacute endocarditis.subacute endocarditis.

Specific disease of the vessels like:Specific disease of the vessels like:

PAN, temporal arteritis, HTN.PAN, temporal arteritis, HTN.

Hematological disorders of all types Hematological disorders of all types can manifest in the fundus.can manifest in the fundus.

Almost all metabolic disorders can Almost all metabolic disorders can affects the eye: affects the eye:

DMDM ::DR, cataract, RE, DR, cataract, RE, ophthalmoplegia.ophthalmoplegia.

HypothyroidismHypothyroidism : : cataractcataract Wilson’s diseaseWilson’s disease..

Thyroid eye diseaseThyroid eye disease: :

Exophthalmos, Lid retraction.Exophthalmos, Lid retraction.

Infections: Infections: (Syphilis,Toxoplasmosis, Rubella)(Syphilis,Toxoplasmosis, Rubella)

Mucocutaneous Mucocutaneous disorders: disorders:

SJS, pemphigusSJS, pemphigus

Elastic tissue: Elastic tissue:

(Pseudoxanthoma (Pseudoxanthoma elasticum)elasticum)

Allergy: VKCAllergy: VKC

Chromosomal abnormalities: Chromosomal abnormalities:

Trisomy: 13,15, 21.Trisomy: 13,15, 21.

The eye is a delicate indicator of The eye is a delicate indicator of poisoning:poisoning:

-Morphine addict -Morphine addict → → meiotic pupilmeiotic pupil

-Lead poisoning, vitamin A -Lead poisoning, vitamin A intoxication intoxication

→ → papilledemapapilledema

• I could go on and on about the discoveries I could go on and on about the discoveries possible in our most important square possible in our most important square

inch.inch.‘’‘’EYE’’EYE’’

90% of our information reaches our brain 90% of our information reaches our brain

via sight.via sight.

Unfortunately, of all the parts of the body, Unfortunately, of all the parts of the body,

the eye is the most vulnerable to minor the eye is the most vulnerable to minor

injury.injury.

What are the objectives of What are the objectives of the comprehensive the comprehensive

ophthalmic evaluation?ophthalmic evaluation?

Obtain an ocular and systemic history.Obtain an ocular and systemic history.

Determine the optical and health Determine the optical and health status of the eye and visual system.status of the eye and visual system.

Identify risk factors for ocular and Identify risk factors for ocular and systemic disease.systemic disease.

Detect and diagnose ocular diseases.Detect and diagnose ocular diseases.

Establish and document the presence Establish and document the presence or absence of ocular symptoms and or absence of ocular symptoms and signs of systemic disease.signs of systemic disease.

Discuss the nature of the findings and Discuss the nature of the findings and the implications with the patient.the implications with the patient.

Initiate an appropriate response.Initiate an appropriate response. e.g. further diagnostic tests, e.g. further diagnostic tests,

treatment, treatment, or referral.or referral.

HISTORYHISTORY

It is a gathering information process from the It is a gathering information process from the patient guided by an educated and active mind.patient guided by an educated and active mind.

It is a selective guided and progressive It is a selective guided and progressive elicitation and recognition of significant elicitation and recognition of significant informationinformation

History by skilled person can arrive at the History by skilled person can arrive at the proper diagnosis in 90% of patients.proper diagnosis in 90% of patients.

It gives vital guidance for: It gives vital guidance for:

(a) physical examination(a) physical examination

(b) laboratory work(b) laboratory work

(c) Therapy(c) Therapy

Failure to take history can lead to missing Failure to take history can lead to missing vision or life threatening conditions. vision or life threatening conditions.

Chief complaint: Chief complaint: ’’The patient’s own words’’’’The patient’s own words’’

‘’‘’she cannot see with the RE’’she cannot see with the RE’’

You should not come to conclusion that her problem You should not come to conclusion that her problem is nearsightedness and write down “Myopia of RE”.is nearsightedness and write down “Myopia of RE”.

• The patient needs will not be satisfied until he/she The patient needs will not be satisfied until he/she has received an acceptable explanation of the has received an acceptable explanation of the meaning of the chief complaint and its proper meaning of the chief complaint and its proper management.management.

History of the Present Illness:History of the Present Illness:

Detailed description of the chief complaint Detailed description of the chief complaint to understand the symptoms and course of to understand the symptoms and course of the disorder.the disorder.

Listen andListen and question and then write down in question and then write down in orderly sequence that make sense to you.orderly sequence that make sense to you.

* * The time sequence The time sequence when, How fast, what order did events occur? when, How fast, what order did events occur?

** Frequency, intermittency Frequency, intermittency ** location, Laterality location, Laterality

* * SeveritySeverity * * Associated symptoms Associated symptoms

* * Documentation (old records, Documentation (old records, photo) photo)

e.g ptosis, proptosis, VII N palsy.e.g ptosis, proptosis, VII N palsy.

gradual painless decrease vision both eyes for gradual painless decrease vision both eyes for 1y.1y.

Sudden painless decrease vision RE for 10 minSudden painless decrease vision RE for 10 min..

““cannot see with RE”!!cannot see with RE”!!• ? Only distance vision blurred.? Only distance vision blurred.

• ? Blind spot is present in the center of VF? Blind spot is present in the center of VF

• ? Right side of VF of the RE lost? Right side of VF of the RE lost

• ? Right VF of both eyes lost? Right VF of both eyes lost

• ? A diffuse haze obscures the entire field of RE? A diffuse haze obscures the entire field of RE

Each of these has different diagnostic implicationEach of these has different diagnostic implicationMost pt. has difficulty providing precise and concise descriptionMost pt. has difficulty providing precise and concise description

Disturbances of vision:Disturbances of vision:

• Blurred or decreased central visionBlurred or decreased central vision• Decreased peripheral vision. Decreased peripheral vision. (glaucoma)(glaucoma)

• Altered image size. Altered image size. (micropsia, macropsia, metamorphopsia).(micropsia, macropsia, metamorphopsia).

• Diplopia Diplopia (monocular, binocular)(monocular, binocular)

• FloatersFloaters

• Photopsia (flash of light)Photopsia (flash of light)

• Color vision abnormalities.Color vision abnormalities.

• Dark adaptation problems.Dark adaptation problems.

• Blindness Blindness (ocular, cortical).(ocular, cortical).

• Oscillopsia Oscillopsia (shaking of images).(shaking of images).

Ocular pain or discomfort:Ocular pain or discomfort:

• Foreign body sensationForeign body sensation• Ciliary pain Ciliary pain (aching, (aching,

severe pain in or around the eye, often radiating to the ipsilateral severe pain in or around the eye, often radiating to the ipsilateral forehead, molar area)forehead, molar area)

• PhotophobiaPhotophobia

• HeadacheHeadache

• BurningBurning

• DrynessDryness• Itching: Itching: patient rub the eye vigorously (allergy)patient rub the eye vigorously (allergy)

• Asthenopia Asthenopia (eye strain)(eye strain)

Abnormal ocular Abnormal ocular secretions:secretions:

• Lacrimation, epiphoraLacrimation, epiphora

• DrynessDryness

• Discharge Discharge (purulent, mucopurulent, mucoid, (purulent, mucopurulent, mucoid,

watery)watery)

• Redness, opacities, Redness, opacities, massesmasses

• AnisocoriaAnisocoria

Family history:Family history:

Many eye conditions are inherited Many eye conditions are inherited RE, glaucoma, strabismus, retinoblastoma, neoplastic, RE, glaucoma, strabismus, retinoblastoma, neoplastic,

vascular disordersvascular disorders

• Familial systemic disease can be helpful in Familial systemic disease can be helpful in ophthalmic evaluation and diagnosis ophthalmic evaluation and diagnosis

Atopy, thyroid diseases, DM, certain malignancies.Atopy, thyroid diseases, DM, certain malignancies.

• Ask about any eye problem Ask about any eye problem in the family background?in the family background?

• Ask specifically about Ask specifically about corneal diseases, corneal diseases, glaucoma, cataract, retinal glaucoma, cataract, retinal diseases or other heritable diseases or other heritable ocular conditions.ocular conditions.

Ask questions designed to confirm or exclude your Ask questions designed to confirm or exclude your tentative tentative diagnosisdiagnosis

- significant positive- significant positive

- significant negative- significant negative

‘’‘’Significant is equal to expected’’Significant is equal to expected’’

predict the physical and lab. finding likely to be predict the physical and lab. finding likely to be

present.present.

any discrepancy between the history and physical any discrepancy between the history and physical examination examination requires explanationrequires explanation

Ophthalmic examinationOphthalmic examinationOphthalmic examination

The Purpose is to evaluate:The Purpose is to evaluate: visualvisual eye eye

movementmovement

1.1. FunctionFunction non visual non visual

alignmentalignment

2.2. Anatomy Anatomy the adnexa the adnexa (lid and (lid and

periocular tissues)periocular tissues) the globe the globe

the orbitthe orbit

Ophthalmic examinationOphthalmic examination• Visual acuityVisual acuity• External examinationExternal examination• Motility and alignmentMotility and alignment• Pupil examinationPupil examination• Slit lamp biomicroscopySlit lamp biomicroscopy• Tonometry Tonometry • OphthalmoscopyOphthalmoscopy

• GonioscopyGonioscopy

• RetinoscopesRetinoscopes

Vision:Vision:

• Vital sign (MUST)Vital sign (MUST)• Good visionGood vision intact neurological visual intact neurological visual

pathologypathology

structurally healthy eyestructurally healthy eye

Proper focusProper focus

• SubjectiveSubjective

How to test the vision?How to test the vision?

• display of different –display of different –sized targets shown at a sized targets shown at a standard distance from standard distance from the eye.the eye.

• Snellen chart.Snellen chart.• 20/20, 6/620/20, 6/6• Uncorrected, correctedUncorrected, corrected

Testing poor vision:Testing poor vision:

• If the patient is unable to read the If the patient is unable to read the largest letter <(20/200)largest letter <(20/200)

• Move the patient closer e.g. 5/200Move the patient closer e.g. 5/200• If patient cannot read:If patient cannot read:

-- count fingers (CF)count fingers (CF)

-- hand motion (HM)hand motion (HM)

-- Light perception (LP)Light perception (LP)

-- No light perception (NLP)No light perception (NLP)

External examination:External examination:

• Evaluate by gross Evaluate by gross inspection and inspection and palpation.palpation.

• Ocular adnexa. (lid, Ocular adnexa. (lid, periocular area)periocular area)

• Skin lesions, Skin lesions, growths, growths, inflammatory inflammatory lesions.lesions.

• PtosisPtosis

• Proptosis, exophthalmos, Proptosis, exophthalmos, enophthalmosenophthalmos

• Palpation of bony rim, Palpation of bony rim, periocular soft tissue.periocular soft tissue.

• General facial General facial examination e.g. examination e.g. enlarged preauricular enlarged preauricular lymph node, temporal lymph node, temporal artery prominence.artery prominence.

Ocular motility:Ocular motility:

Evaluate Evaluate -- AlignmentAlignment

-- MovementsMovements

• Misalignment of Misalignment of the eyesthe eyes

Movement:Movement:

• Follow a target with both eyes in each Follow a target with both eyes in each of of the four cardinal directions of gaze.the four cardinal directions of gaze.

• Note Note --speedspeed --smoothnesssmoothness -- rangerange --symmetrysymmetry

--unsteadiness of fixation unsteadiness of fixation e.g nystagmus e.g nystagmus

Pupils:Pupils:

Examine for size, shape, Examine for size, shape, reactivity to both light reactivity to both light and accommodation.and accommodation.

• Direct response and Direct response and consensual response.consensual response.

• Afferent pupillary defect Afferent pupillary defect (Marcus Gunn pupil)(Marcus Gunn pupil)

• Efferent pupillary defect.Efferent pupillary defect.

• Pupillary abnormalities:Pupillary abnormalities:

-- neurologic diseaseneurologic disease

-- previous inflammation – adhesionprevious inflammation – adhesion

-- acute intraocular inflammation acute intraocular inflammation - - spasmspasm

- - atonyatony

-- prior surgical traumaprior surgical trauma

-- effect of systemic or eye effect of systemic or eye medicationmedication

-- benign variation of normalbenign variation of normal

Slit lamp examination:Slit lamp examination:

Is a table-mounted binocular Is a table-mounted binocular microscope with special microscope with special illumination source.illumination source.

A linear slit beam of light is A linear slit beam of light is projected onto the globe projected onto the globe – optic cross section of – optic cross section of the eye.the eye.

• Slit lamp alone, the Slit lamp alone, the anterior half of the anterior half of the global (anterior global (anterior segment) can be segment) can be visualized.visualized.

Tonometry:Tonometry:

– The globe is a closed compartment with The globe is a closed compartment with constant circulation of aqueous humor.constant circulation of aqueous humor.

– This maintains the shape, and relatively This maintains the shape, and relatively uniform pressure within the globe.uniform pressure within the globe.

– Normal pressure 10 – 20 mmHg.Normal pressure 10 – 20 mmHg.

Types of tonometry:Types of tonometry:

Schiotz tonometerSchiotz tonometer

Goldman tonometerGoldman tonometer

• Glodmann Glodmann applanation applanation tonometertonometer

Tonopen tonometerTonopen tonometer

Perkin tonometerPerkin tonometer

Air-puff tonometerAir-puff tonometer

Ophthalmoscopy:Ophthalmoscopy:

Direct ophthalmoscopy:Direct ophthalmoscopy: handheld instrument.handheld instrument. standardstandard part of the general part of the general

medical examinationmedical examination.. PortablePortable

Indirect ophthalmoscopeIndirect ophthalmoscope

Indirect Ophthalmoscoy:Indirect Ophthalmoscoy:

1. provide much wider field of view1. provide much wider field of view

2. less magnification (3.5X with 20D lens)2. less magnification (3.5X with 20D lens)

3. brighter light source – better view.3. brighter light source – better view.

4. Binocular – steroscopic view.4. Binocular – steroscopic view.

5. Allow entire retina examination till the 5. Allow entire retina examination till the

periphery.periphery.

Disadvantage:Disadvantage:

1. 1. Inverted retinal image.Inverted retinal image.

2. 2. Brighter light is uncomfortable to theBrighter light is uncomfortable to the

patient.patient.

– Special lenses:Special lenses:

-- Goniolens Goniolens

- - other lenses allow other lenses allow evaluation of the posterior evaluation of the posterior segment.segment.

Retinoscope Retinoscope

RetinoscopyRetinoscopy