Ophthalmology Guideline : history and examination

By Dr. Sidrah Latif, PGR Eye Unit III (Class of 2013)

For downloadable version, click here
Examination videos by Dr. Ali Ayaz here


You are reading this document which means you are done with giants of Pathology and Community Medicine already, so my heartiest Congratulations to all of you for slaying the two big monsters of fourth year and you are hopefully unscarred as yet. Welcome to the warm arms of Ophthalmology. We hope to provide a soothing balm to your stinging burns (if any left over from your patho/cmed encounters).
Ophthalmology is relatively ignore-able subject and we all are guilty of that. All the examiners in the vivas are there to pass you, until you by your sheer will and desire blunder for a supplementary. Still, we try out best to rid us of you people in the first go.
Following are the salient points for you to follow in your viva. The history and breakdown schematic presentation of methods to follow are as under. 

HISTORY:
·         Biodata:
Name
Age
Sex
Marital status
Occupation
Resident of
How to present: My patient M.Riaz S/o M. Bashir, 45 years of age, married and a farmer by profession , resident of district narowal, presented to the OPD/emergency on 23/11/17 with the presenting complaint of……………..

·         Presenting Complaints:
Gradual/Sudden
Painless/Painful
Progressive/ Non-progressive
DECREASE OF VISION---- (duration)

·         History of Presenting Illness:
My patient a known diabetic for past 10 years using oral hypoglycemics/insulin with controlled/uncontrolled diabetic status, presented with the presenting complaint of Gradual painless progressive decrease of vision for past few months/about a year. The decreased vision was like a fog coming infront of eye, and it became increasingly difficult to recognize faces (cortical cataracts). The decreased vision progressed with time so much so that now it is hindering the daily activity of the patient/ patient feels difficulty during driving at night (posterior subcapsular)/ patient is unable to carry out normal daily activity….
For all presenting complaints complete following points:
ODPARA
Onset > when did the complaint start in time
Duration>  for how long the complaint has been so
Progression>  has the complaint progressed over time
Associated features>  is there any accompanying
Pain in eye
Headache (frontal could be due to stress, generalized due to refractive errors, in ipsilateral temple with raised IOP)
Photophobia (is different from simple squinting in sunlight, photophobia means a deep pain in eye with exposure to light that occurs because of ciliary spasm)
Itching
Redness
Watering
Floaters (like a fly or a web moving with the eye movements)
Flashes of lights are like a star breaking in the sky occurring with closed eyes, if the patient doesn’t describe it like so then the patient doesn’t have it!
Glare is spreading of light; occurring in posterior subcapsular cataract
Halos around light form whenever there is any water retention in the clear refracting media of eye namely the cornea or the lens; so corneal edema and incipient cortical cataract with water vacuoles cause coloured halos
Diplopia (uni-ocular diplopia occurs with a subluxated lens, binocular diplopia means a squint/nerve palsy)
Relieving factors
Aggravating factors+Diurnal variation

·         Past Ocular history
GST-MILO
History of:
Glasses (myopes are pre-disposed to RDs)
Surgery (previous surgery predisposes to RD, glaucoma surgery means patient has glaucoma etc)
Trauma (trauma causes superotemporal quadrant tears and Rhegmatogenous RDs)
Medications (topical steroid misuse causes both cataract and glaucoma)
Injections (intravitreal avastins are given in diabetics)
Lasers (panretinal photocoagulation of a diabetic patient may be done)
Other eye
·         Past medical history
Ask about
Diabetes
Hypertension
Ischemic heart disease (patient is on anti-coagulants may need to be stopped before surgery, beta-blockers can’t be given)
Stroke (like IHD can be on anti-coagulants)
Asthma/COPD (patient may not be able to lie down straight for surgery)
Arthritis (patient of arthritis may misuse steroids, plus also association with uveitis)

·         Family history
Ask about
Glaucoma (any of your family members loose sight in their eye?)
Squint (may involve siblings)
Retinoblastoma
Night blindness, Retinitis pigmentosa

·         Birth history
Important in squint patients, birth trauma can cause squint

·         Drug history for anti-coagulants, oral steroids, beta-blockers etc

·         Socio-economic status

EXAMINATION:
1.       Visual acuity
2.       Colour Vision
3.       Field of Vision
4.       Pupillary light reflexes
5.       Torch examination
6.       Extra-ocular motility
7.       Ptosis/squint
8.       Regurgitation test
9.       Digital tonometry
10.   Direct ophthalmoscopy

VISUAL ACUITY
Make the patient stand at 6 m from the chart; occlude one eye with the palm of hand, record the line read by the patient. Distance of patient from chart is numerator, and the line denoted by the distance from which a normal person reads that line is denominator. 6/60 hence means that patient can read at 6 m the line which a normal acuity person reads at 60m. 1/60 means that patient is reading the same line at distance of 1 m. If a patient is unable to read the largest letter at 1 m distance, then ask him to count fingers at 3 ft., then 2 ft., then 1 ft., and then check for hand movement perception. If the answer is nada, then check light perception and projection. Light perception is when you shine torch directly in patient’s eye and he perceives it from his macula. For checking projection shine the light obliquely on patient’s eye whilst he looks straight ahead. Your aim is to check the working of peripheral retina and not the macula when checking projection of light. Hence LP and PR are for macular function and peripheral retinal function respectively.
VA sc (without glasses)
VA cc (with glasses)
BCVA (best corrected visual acuity with pinhole over glasses)

COLOUR VISION
Use some coloured pointer to ask about red and green colour primarily (affected in optic nerve dysfunction) or take the red cap of dilating drops, hold it infront of torch and show it to the patient first with one eye then the other and ask him to compare. Is it more laal or more khatta (orangish).

FIELD OF VISION
Do it by using confrontation method. Sit in front of patient, close your right eye to check patient’s left and vice versa. Ask the patient to count fingers that you hold up in four quadrants, compare the field with your own, if you can see fingers but the patient can’t then his or field is restricted, keep on moving towards center point of visual field until patient is able to count the fingers.

PUPILLARY LIGHT REFLEXES
Keep two torches with good light in your hand, ask patient to look at a distant target, stand on one side of patient.
Shine torch in Right eye and note the Direct Light Reflex in Right eye. Illuminate the Left eye and shine torch again in Right eye while noting constriction in the illuminated left eye. This is Right eye’s indirect light reflex. After completing right eye then move to left. Don’t fumble between checking direct in right and left then stopping to think to check indirect of which is which.
Repeat this on the other eye that is the left and record direct and indirect light reflex.
Do the swinging torch light test.
Check pupillary constriction with accommodation.
Comment on pupillary light reflexes as:
Pupils are bilaterally round, regular and reactive with intact direct and indirect light reflexes. There is no RAPD on either side. Pupils are constricting on accommodation.
Right pupil is round, regular and reactive, with intact direct and indirect reflex. Left pupil is round, regular but sluggish direct and indirect reflex is noted. There is grade 2 RAPD present in left eye. Normal response to accommodation is noted.  (an example of left optic nerve dysfunction due to glaucoma/neuritis)

TORCH EXAMINATION
Diffuse illumination by shining light over nasal bridge, note symmetry of the dace, eye brows, any lid droop, obvious proptosis etc. Ask the patient to look in the light and record the corneal reflections (Hirschberg test). (Remember corneal reflection test is the only test in which you ask the patient to look into the torch. For all other practical purposes you are giving a distance target to the patient).
One eye examination note eyelids, eye lashes, punctum, palpebral conjunctiva, bulbar conjunctiva and fornices, and then cornea. Describe any opacity covering cornea as covering one third, less than one third, one half or more than half of cornea, or being in the nasal or temporal or superonasal/inferonasal or superotemporal/inferotemporal quadrant. Note any vascularization etc. Then check the anterior chamber depth by shining light from the side and noting the crescent of light forming at limbus, always compare the AC depth with the other side before commenting. Then finally look at pupil for its site, size, shape, colour and reflexes. (IF SOMEONE ASKS YOU TO CHECK THE PUPILS OF A PATIENT START WITH SITE, SIZE, SHAPE, COLOUR AND THEN REFLEXES. IF SOMEONE ASKS TO CHECK REFLEXES THEN GO DIRECTLY TO THE REFLEXES PART. HOWEVER NEVER EVER FORGET TO NOTE THE SITE AND SIZE AND COLOUR OF THE PUPIL). Note the purkinje images to make in your mind whether the patient is normophakic, pseudophakic or aphakic.
Grey coloured pupil ànormophakic
Black coloured pupil àpseudophakic if one purkinje image moving against the motion of torch in your hand is seen, aphakic if the against moving purkinje image is not seen
White coloured pupil à could be brilliant/pearly white which is mature cataract (no iris shadow, no purkinje images seen. Could be slate grey white or mildly yellow tinged (don’t call it yellow though) iris shadow will be visible and this will be immature cataract. Donot tell that it is nuclear sclerosis or cortical cataract till you can dilate patient and see on slit lamp! No commenting on the type of cataract in torch light please.
So the scheme in torch exam is
1.       Diffuse illumination
2.       Eyelids
3.       Conjunctiva
4.       Cornea
5.       Anterior chamber
6.       Iris
7.       Pupils
8.       Lens

EXTRA-OCULAR MOTILITY
Pursuit movements
Ductions – uniocular movements
Versions – binocular movements (In which the angle between the visual axes of the eyes stays same)
Vergences – binocular movements (in which angle between the visual axes changes)
Saccades

PTOSIS EXAMINATION
Check Margin Reflex Distance (MRD), Palpebral fissure height (PFH) and Levator Function (LF) alongwith Bell’s phenomenon

SQUINT EXAMINATION
After visual acuity, pupils, corneal reflection test and extra-ocular motility request the examiner that you wish to check patient’s stereopsis using titmus fly test, but that won’t be available so proceed on to the cover-uncover test, followed by prism cover test (Which you won’t do). Always check stereopsis before doing cover-uncover test because it breaks the fusion of the patient’s brain and decreases the depth perception.
Cover test:
1.       Ask patient to fixate at a distance target.
2.       Cover the fixating/normal eye with an occlude while observing the squinted/non-fixating eye and record its movement (Primary deviation).
Uncover test:
1.       Continue as extension of cover test and uncover the eye you covered before.
2.       Note the movement of the eye being uncovered (Secondary Deviation).  
Cover-uncover test is sufficient to characterize the squint and diagnose it as Right/left exo/esotropia or Alternating exo/esotropia. (Mostly in exams you get alternate exos).
Alternate Cover test:
1.       Alternately cover both eyes
2.       Note any increase in the manifest deviation.
Alternate cover test is used to being out the latent part of any deviation, so as to measure the total deviation.

REGURGITATION TEST Ask the patient to look up, hold light in one hand to illuminate medial canthus and with the little finger of the other hand press at medial canthus in the hollow that you feel below the medial canthal tendon and push up and in. You should be looking at punctum to check any outpouring of tears from there. When regurgitation is positive it will be so glaringly obvious that you can’t miss it. If you are in doubt it means it is negative. Trust your judgment and don’t call it positive.
 
DIGITAL TONOMETRY Rest your fingers on the forehead of the patient and use both the index fingers, ask the patient to look down and then push with one finger to feel the ripple of eyeball at the other finger. Always compare with the other side and give a comparative finding (not absolute).
This finished the examination of the eye. Hopefully.

DISCLAIMER: I am not responsible if I missed something, or if something I mentioned was erringly wrong, or if your examiner refuses to accept your answer, or if they expect something else. This is just a rough guideline, kindly improve upon it yourselves.

With best wishes!
Sidrah.

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