Dr Sean Every Dr Jo-Anne Pon - s3.amazonaws.com · for visual field defects respecting the vertical...
Transcript of Dr Sean Every Dr Jo-Anne Pon - s3.amazonaws.com · for visual field defects respecting the vertical...
Dr Sean EveryOphthalmologist
Southern Eye Specialists
Christchurch
8:30 - 9:25 WS #70: Eye Essentials for GPs
9:35 - 10:30 WS #80: Eye Essentials for GPs (Repeated)
Dr Jo-Anne PonOphthalmologist
Southern Eye Specialists,
Christchurch Hospital, Christchurch
How to usefully examine an
eye in General Practice
Sean Every
Ophthalmologist
Cataract and Vitreo-Retinal Surgeon
The problem
~2% of consultations in General Practice are eye related
Variable experience - some GP’s “scared stiff of eyes”
Commonly no slit lamp to examine the eye
Busy clinics
Variable distance to the nearest optometrist, hospital or ophthalmologist
Don’t underestimate yourselves
Pay careful attention to the symptoms reported
given the difficulty of accurately evaluating the
signs
Examination starts with history
Pain
Photophobia
Blurred vision (can they blink it away?)
Double vision
Trauma (mechanism of trauma)
History
Ocular
Myopia
Inflammatory eye disease
Eye operations – surgery, laser
Eye drops
Medical
Cardiovascular risk factors
Diabetes
Family ocular history
Glaucoma
Macular degeneration
Squints/amblyopia
Tools in the tool box
Hardware
Snellen chart
Pinhole
Ophthalmoscope
+/- penlight
Visual targets
Red
Interesting toy which a child will look
at
Pharmaceuticals
Topical local anaesthetic
Fluorescein stain
Dilating drops
Gutt Tropicamide 1%
Topical local anaesthetic
Might be the first useful thing you can
do
Aid diagnosis
localises pathology to ocular surface
Analgesia
Allow accurate VA test
Allow examination
Snellen Acuity The single most useful summary of eye
anatomy/physiology/optics and function
1. Well illuminated chart at the
correct distance
1. Make sure they haven’t put
reading glasses on
“are these the glasses you use for
distance or driving”
3. Effective occlusion other eye
• Palm of the hand
• NOT fingers
What does a Snellen VA mean??
The top number is the test distance in metres
The bottom number is taken from the lowest line read on the chart
A pseudo-fraction which measures the size of detail they can resolve
6/60 is 10X the size of the 6/6
6/24 is 2X the size of the 6/12
Can’t read the top line?
Action
Reduce the distance between patient
and chart
6m reduce to 3m, 1m
Count fingers
Perception light
Projects accurately
No projection
No perception of light
Notation
— 3/60 1/60
— 1/CF
— PL
— NPL
The pinhole acts like a universal
spectacle lens by reducing the blur on the retina
refractive error improves with pinhole
Refer optometry for glasses
other eye pathology does not improve
with pinhole
Refer ophthalmology
“I left my glasses in the car Dr” – use
a pinhole
Near Acuity: bedside in the rest home
Search Near Vision Test on your phone
Testing acuity in kids
- a skill which requires training and practice
0-3 years
Corneal reflex
Red reflex
Fix and follow a target
4-6
Identify 6/12 line each eye (not
binocularly)
Some 4 yr olds won’t cope
7+
6/9 or better
Ophthalmoscope
Red reflex
Corneal reflexes (testing alignment)
Magnifying lens (to look at skin lesions
or the anterior segment)
Cobalt blue filters to look for
fluorescein staining
Funduscopy
Start at zero
Alignment: corneal light reflexes- Kids: “my childs’ eyes aren’t straight”
- Adults: “I’m seeing double”
Normal
Squint
convergent divergent
Pseudo esotropia
Pupils: red reflex
Media opacities
Symmetry
Colour
Brightness
Tips
Dim room
Can use parents reflex as a baseline
External eye examination
symmetry
Lids
Sclera show
Remember a significant portion of
ocular surface under the lids
Orbit
Unilateral red eye
symmetry
Right ptosis
Left proptosis
Left upper lid
retraction
Right unilateral red eye
Motility….- don’t get bogged down
- forget about the cover test
- history trumps everything even if examination seems normal
Sixth Cranial nerve
Lateral Rectus
Horizontal diplopia
Fourth Cranial nerve
Superior Oblique
Vertical/torsional Diplopia
Third Cranial Nerve
Vertical
Horizontal
Ptosis
Pupil dilated
PEARL control fixation to neutralize the near reflex
Equal
Iris stuck
Autonomic Innervation
3rd CN palsy
Horner’s
Anticholinergic blockade
gardening
oven cleaners
nebulized asthma drugs
Reactive to light
Individually
Relative
Relative afferent pupillary defectcompare retina/optic nerve function between the eyes
RAPD
Objective
Swinging flashlight test
Pupil dilates on affected
side with light stimulus
A great test but difficult to
do well and hard to detect
in subtle disease
Look it up on youtube….
Brightness Sensitivity
Subjective
Easy to do
“is the light the same
brightness in each eye”
Visual Fields (VF)
Is a test of
retina
optic nerve
visual pathway
visual cortex
VF defects can be
Absolute
Relative
Test strategy to detect relative VF defect
Control patient fixation
Lots of reminding and prompting
Test strategy depends on patient
Left Right
VF test optionsfor visual field defects respecting the vertical midline
1. “look at my nose”
“keep your eye still”
“can you see all of my face with
the edge of your vision”
“which part is missing”
2. Simultaneous finger counting
3. Red desaturation across the
vertical midline
Anterior segment of the eyeanterior to the iris
Direct unaided observation
Use the magnifying lenses in the
ophthalmoscope
Cornea should be clear
Fluorescein staining
Use strips rather than drops
Drops pool in the tear film and so
much fluroescein present that can’t
see any corneal staining
Funduscopy
Don’t be afraid to dilate if clinical
scenario justifies
Risk of precipitating acute glaucoma
incredibly low
No one will blame you!
Possibly done them a favour
At risk if their distance glasses are
like high powered magnifiers
Good for optic disc and macula
High magnification
Small field of view