Introduction to Ophthalmology and External Eye Examination

Tuesday, November 18, 2014

9:00 a.m. to 10:20 a.m.
Auditorium B, Queen Lane
Marvin Greenbaum, M.D.

Objectives:
1.
2.

Learn the fundamentals of the ocular examination.

Learn to spell, "ophthalmology".

QUICK DEMONSTRATION OF THE EXAM:

-Visual Acuity Test: performed with corrective lens
1)
Have the patient, cover one eye with the palm of their hand
2)
Ask them to read a specific row of numbers on the Snellen eye chart
-Visual Field Test: w/o correction
1)
Have the patient look at your nose
2)
Using both of your hands, test each eye by holding
1, 2, or 5 fingers and asking them the total number of fingers that they see.
-Look for facial symmetry and assess the lids
-Check the pupils
1) efferent system
2) afferent system
3) accommodation

shine light in one eye, and let the pupil go down, and then the other.
Pupils should constrict equally.
shine the light in one eye, and then immediately into the other.
hold an object in front of the patient; instruct them to focus, look away
and then back again. Eyes should turn in and Pupils get smaller as they
focus from far to near.

-Extraocular muscles and movement

Check the six cardinal positions of gaze.
-Examine the conjunctiva and sclera
Instruct the patient to look up while you pull the lower lids down; and look down while you pull the upper
lids up.
-Inspect the cornea and iris with your penlight
-Check the depth of the anterior chamber
Shine the pen light onto the eye from a 180 angle
ANATOMY OF THE EYE
(previously included diagrams were removed due to copyright laws)

NOTES:
Patients may worry that they have lost a contact "behind their eye." This can't happen because palpebral
conjunctiva reflects on to bulbarconjunctiva
The sclera is covered by the conjunctiva. This is not normally appreciated unless it is injected with inflamed blood
vessels. Patients may refer to this as red eye," which is not a specific diagnosis.
Uveal tissue refers to the choroid, the ciliary body, and the pigmented epithelium of the iris.
PHYSIOLOGY
An analogy can be made between a camera and the eye: -object rays are focused through a series of lenses (cornea
and lens) through a diaphram (iris) or pupillary aperture and images are focused on the "film" in the back of the
camera (retina).
The cornea is responsible for most of the refractive power of the eye, i.e. it is more refractive than the lens.

EXAM
After taking the patient's history, assess Visual Function. This consists of visual field and visual acuity.
Visual Acuity:
Once upon a time, it was decided that a letter of a certain size, from 20 ft. (6M) away created a 5" arc at the focal
point of the eye. If a person is able to see that size letter from a distance of 20 ft, this was considered to be normal
vision, i.e. 20/20
Testing:

1)

2)
3)
4)
5)
6)
7)

8)

9)
Note:

Ask the patient to cover one eye with the Palm of their hand (Remember to say palm
so that they don't press the eye and-thereby blur its vision when you want to test it
next.)
Ask the patient to read the smallest line possible.
If the patient can read the row of letters designated as 20/20 from 20 ft. away, the
patient has 20/20 vision.
If the patient can only read larger letter, i.e. ones that create the same arc from 50 ft.,
they have 20/50 vision etc.
If the patient can't read the largest (20/400) access visual acuity as follows:
Hold 1, 2 or 5 fingers in front of the patient and ask them to count the number of
the number of fingers. If they can do this, this is recorded as Count Fingers Vision (CF)
If the patient can't count your fingers, move your hand up and down and side to side.
Ask patient if they can see your hand and tell you the the direction of movement.
This is recorded as Hand Motion Vision (HM)
If there is no HMV, turn penlight on and off in front of the patient.
Ask the patient if they can tell if the light is on or off. This is recorded as Light
Perception Vision (LP).
If LP vision is not present, record this as a No Light Perception (NLP)

If one doesn't have a Snellen chart, use a newspaper or something. It is very important to get a baseline visual acuity. This is particularly important in TRAUMA, before any manipulations are done to
the patient (e.g. dilation).

Visual acuity tests only the fovea. The visual field assessment is needed to test the rest of the visual field.

CONFRONTATION VISUAL FIELDS

Test with one of the patient's eyes covered. -The finger-wiggling test may be confusing, and may give the patient a
larger object to see than is intended. But some instructors and texts still use it; this method is better for general
use.
-One is really looking for lesions that obey the horizontal or vertical planes.

1)
2)
3)

Ask the patient to look at your nose, thereby making it the center of their visual field, crossing through
the horizontal and vertical fields.
Hold up both hands at once. This forces the patient to look straight ahead.
Use 1, 2 or 5 fingers, moving hands through the horizontal plane, above and below.

SYMMETRY OF THE FACE

-Very important!!,

-OB8ERVE THE PATIENTS FACE

-look for symmetry of the -

forehead and creases

eyebrows
upper lid (Nml. covers limbus 1-2mm)
lower lid (Nml. covers limbus 1 mm)
pupils; equal size?
irises; same color?
cheeks, nose, mouth

LIDS AND FISSURES

Check for position, movement and structure.
Muscularture:
1) Orbicularis oculi - innervated by CN VII
- functions to close lid
Slide:
Patient with asymmetrical eyebrows, forehead creases on one side, one lid open, one
somewhat closed, eyes rolled up.--Dx. --Bell's Palsy - peripheral nerve palsy
(peripheral since there is forehead involvement)

2) Levator Palpebri

- innervatd by CNIII
- functions to open lid
- attaches to the anterior
border of the tarsal plate of eyelid

3) Superior tarsal- or Muellers muscle

- (sympathetic innervation)
- accounts for 1-2 mm of lid elevation
PUPILS
PERRLA

Pupils Equal & Round Reactive to Light and Accommodation

20% of normal people have anisocoria (unequal pupils), usually subtle.

If you know that pupils are equal, round and reactive to light they will accomodate.
1)

Accommodation - Patient focuses on an object, looks at the

distance and back again to refocus.
Eyes turn in. Pupils get smaller

2)

Pupillary light Reaction

Afferent Limb

Efferent Limb

Test of Efferent
Test of Afferent

shine light in eye

light travels along the optic nerve
-50% of the fibers cross at the chiasm
-nerve impulse enters the lt & rt.
Edinger-westphal nucleus.
Lt & RT CNIII -- to the cilliary
ganglion --- Pupil constricts
Shine a light in one eye and both pupils
should constrict if CNIII is intact.
shine light in one eye (both pupils
constrict)
quickly, shine it in the other (there
should be no change as the amount of
light is the same)
Quickly, go back to the first eye.
(Again, there should be no change)
Thus, this is a normal afferent limb.

Marqu Gunn Pupil (Afferent Pupillary Defect) - This is an

afferent lesion.
for example, optic n. lesion in the left eye
shine light in rt. eye, pupils constrict
move the light to left and the pupils dilate because the E-W nucleus is not receiving the
amount of light input

EXTRAOCCULAR MUSCLES
- 4 recti

muscles
- 2 oblique muscles
- Mnemonic for innervation; SO4 and 6RE, all the rest supplied by 3"
(SO = Superior Oblique )
( RE= Rectus Externus)

Cardinal Positions of Gaze positions to best evaluate the actions of the muscles
Instruct patient to:
1)
2)
3)
4)
5)
6)

look
look
look
look
look
look

in
out
up & out. down & out
up and in
down & in

medial rectus muscle, CNIII

lateral rectus muscle, CN VI
superior rectus muscle, CN III
inferior rectus muscle, CN III
inferior oblique muscle, CNIII
superior oblique, CN IV

-Tropia -

one eye deviates when both eyes are open and focusing

-Phoria -

latent deviation - tendency for an eye to deviate

usually, a latent deviation is held in check by fusion, i.e. both eyes focusing on an object

-Hirschberg Test - shine pen light in the patient's face - normally, the pupillary light
reflex falls symmetrically on the cornea in about the center of the pupil, (maybe slightly nasal) -Tropias can be
described as:
esotropia - deviated in
exotropia - deviated out
hiypertropia deviated up
hypotropia deviated down

CONJUNCTIVA, SCLERA. AND CORNEA

At this point in the exam, you are almost ready to dilate the eyes for a funduscopic exam!
FIRST, however, it is very important; to check the depth of the anterior chamber as drugs for dilation may
precipitate an acute narrow glaucoma in eyes with very narrow anterior chamber angles.
ANTERIOR CHAMBER DEPTH
l. Shine the pen light onto the patients eye from the side
The iris should be uniformly lit
In a patient with a narrow anterior chamber, only the lateral side of the iris will light up

NOTE:

This will not make the diagnosis of glaucoma but alert you to suspect narrow angles.

Learn to spell

O-P-H-T-H-A-L-M-0-L-0-G-Y

Faculty Disclosure Statement

It is the policy of Drexel University College of Medicine to insure balance, independence, objectivity, and scientific rigor in all its sponsored
educational programs. Educators at medical education activities are required to disclose to the students their financial relationships with the
manufacturer(s) of any commercial products, goods or services related to the subject matter of the program topic.
The intent of this disclosure is to allow participants to form their own judgments about the educational content of this activity and determine
whether the speakers commercial interests influenced the presentation.

I have no financial relationships with manufacturers related to this lecture to disclose. - Marvin Greenbaum, M.D.

Introduction to Clinical Medicine

Ophthalmology Examination

Suggestions for the fundus examination (ophthalmoscope) can be easily summarized:

I

Having checked anterior chamber depth, dilate the pupil when you seriously
want to see the retina.

2.

Especially if you cannot dilate the eye, darken room as much as possible

3.

Try to arrange a comfortable position (e.g., patient sitting on exam table or side
of bed).

4.

Instruct patient to fix on a "distant" spot and think about looking at it, not
looking into the light.

5.

Use your right eye to examine the patients right eye, your left for patient's left.
Move your head, hand, and instrument as a unit, as you pivot to see more of
fundus.

6.

Get in close to patient!

7.

Attempt eventually to use a sequence (e.g., examine disc first, then vessels, then
retinal background).