Post on 29-Mar-2015
In the name of god
Clinical eye examinationHamid Fesharaki MD
Eye department Isfahan University of medical sciences
History & physical examination
Clinical eye examination History & physical examination
Clinical eye examination History & physical examination
Hand Held Acuity Card
Ophthalmic symptoms : pain, redness, itching, burning , F B sensation,
Visual loss
Snellen Chart
Physical examinationvisual acuity: fixation & follow, snellen chart
Clinical examination
Visual acuity: central, peripheralvisual acuity is hard to check due to its subjective nature: depends on the response of the patient (intelligence , previous experience, alertness)
Measurment of visual acuitymonocular vs binocular, wit or without correction
far and near
Accurate clinical eye examinationreduces the para clinical expensive testing Poor ophthalmoscopy may call for ocular sonography, OCT, FA…
Define the best corrected visual acuity firstRefraction is the beginning step of clinical examination clinical judgment without refraction can be miss guiding
RAPD (Retrobulbar neuritis)
Judgment by observation alone may be misleading A relatively pale optic disc Reduced light reflex of fovea Optometrist referral for retinal problem
Refractive error: retinoscopy, subjective refraction including the pin hole , autorefraction.
subjective refraction To find the best corrected visual acuity
Autorefrctor may give wrong numbers
Biomicroscopy
Direct ophthalmoscope
OPHTHALMOSCOPY
Direct ophthalmoscopy and
indirect ophthalmoscopy
through dilated pupil
inexpensive, rapid, efficient
Observation of the fundus structures is very important for clinical diagnosis.
Ophthalmoscopy
Retinal photography
Polaroid photographs
35mm colour slides
Digital images
- Scanner
- Video
- Digital camera
RETINAL EXAMINATION
OPHTHALMOSCOPY
Direct ophthalmoscopy and
indirect ophthalmoscopy
through dilated pupil
inexpensive, rapid, efficient
Visual loss:
1. Refractive error: retinoscopy, subjective refraction including the pin hole , autorefraction. (Irregular astigmatism)
2. Opacity of media: ophthalmoscopy, retinoscopy, biomicroscopy. (red reflex) 3. Retina & Optic nerve : ophthalmoscopic observation, RAPD, visual field,
ERG, EOG, VEP, angiography, OCT, ultrasonography.
(Amblyopia)
Amblyopia: history & phsical: Anisometropia, Isoametropia, Strabismic,
(Monofixation synd) 4 prism base out test
Malingering: age, gain, tricks
Legal writing
Beyond the optic nerve: RAPD,VEP, Visual field, brain imaging
Deprivation
Refractive error Irregular astigmatism
. Opacity of media: ophthalmoscopy, retinoscopy, biomicroscopy. ultrasonography
(red reflex)
Evaluation of retina & optic nerveVisual field: Confrontation, tangent screen
Visual field: Static & kinetic perimetry
Visual field: Static & kinetic perimetry
Evaluation of retina & optic nerve
• Observation: Compare between the two eyes, and compare with the population.
• Correlate between BCVA, clarity of visual pathway and fundascopic findings
• Relative afferent pupillary defect
• Function tests: visual field,VEP, ERG, EOG..
Retina & Optic nerve : Angiography, visual field, OCT, GDX, ERG, EOG, VEP, ultrasonography,
Beyond the optic nerve: Visual field brain imaging: MRI, CTscan
visual field
The pattern of visual field may be diagnostic
EYE EXAMINATION - ROUTINE
History
Visual acuity
Clinical examination of retina
Direct ophthalmoscopy
Indirect ophthalmoscopy
Retinal color photography
Fluorescein angiography
SPECIFICITY AND SENSITIVITY OF
OPHTHALMOSCOPY AND PHOTOGRAPHY
Ophthalmoscopy Photography
(%) (%)
Sensitivity 65.7 87.3
Specificity 93.8 84.8
Owens et al, Diabetic Medicine, 1998
GOLD STANDARD FOR RETINAL SCREENING
Seven 30 - degree field of stereoscopic
photographs taken by a trained technician
Photographs can be taken by a mobile
unit with a camera and later assessed by a
trained reader
Suited to serve even rural communities
Retinal photography is the gold standard for screening diabetic retinopathy
Snellen Chart For Acuity Testing
Checking Visual Fields By Confrontation
Left eye cannot move laterally
Observation External StructuresPupil, iris and eyelids & lashes should appear symmetric
Sclera should be whiteConjunctiva clear