PD Opthalmology

7/30/2019 PD Opthalmology

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PATIENT

DOCTOR II

OPHTHALMOLOGY

Rolando E. Regalado MD, FPCSEENT


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Introduction

As a medical student, you are thephysician of tomorrow as such

you need to understand that the

doctor is a medical detective.

2 most fundamental skills

necessary for the medicalinvestigation

Interrogation and examination


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Doctor Patient Relationship

the doctor must learn to conceal any moraljudgements that he may have about theactions and attitudes of the patient, thephysician should bemoral but not a

moralist genuine kindness and sympathetic

understanding come only from within -

fortunatelymost medical students have more

than a little compassion for their fellowmen, infact, it is a powerful motivating factor in their

selection of a career.


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But that is the trick and glory of medicine.

You must develop a kinship close enough

to succor but not so close as to impairyour objectivity or drain your emotions.

You must identify with the wounded

without feeling the pain; work with thewretched without becoming wretched;

comfort the dying without dying a little

yourself The only function of a physician is to help

people live, and if he cannot do that, then

to help people die with dignity


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Anatomy of the EyeThe Eyeball

- Hollow spheroid

- 25 mm in diameter

- Adult size reached byage of 3

- Composed of 3 layers

and 3 internal zones 3 layersa) Outer fibrons

(cornea/sclera)

b) Middle vasculomuscular(choroid, ciliary bodyand iris uvea or uveal

tract)c) Inner neural layer(retina)

3 internal zonesa) Aqueous

b) Lens

c) Vitreous


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A. Outer Layer

1. Sclera - white of the eye

- radius 12 mm

- 0.4 to 1.0 mm thick- composed of interlacing collagen

fibrils tough and resists

stretching


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Cornea

- covered by tear film gives cornea perfectmirror surface

- 8 mm radius curvature

- 11.5 mm diameter

- 0.5 0.6 mm thick- profuse nerve supply

- 2/3rd of the total reflection of light

-entering the eye occurs (43D) totalpower of the eye (60D)


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Middle Layer

Choroidvascular layer

Ciliary Bodyband between 4-6 mm wide

which lives the interior of the sclera just

behind the limbus

2 functions

a) ciliary processes secretes aqueous

b) ciliary muscles provides the motive

power for

accomodation (the increase in the reflective

power of the lens for near vision)


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Retina- 0.4 mm thick- lines interior 2/3rds of the globe

- consists of pigment epithelium inaternall andtransparent neural portion internally

Neural Part

a) protoreceptors (rods/ cones)

120 million rods

6 million cones

b) 5 types of neurons

1 million nerve fibers

200 connections to 20 or 30 other neurons

c) glial cells

d) cell processes

Inner Layer


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Optic Nerveaxons of the garglion cells is a directextension of the brain

Lens- 9 mm diameter- 5 mm thick

- biconvex

- size increases with age

- provides the adjustable part of the eyesreflective power


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Vitreous Body - transparent avascular jelly whichfills the posterior segment of the globe

behind the lens

- 98 % water

Aqueous Humor- clear liquid similar incomposition to protein-free plasma and fills

the anterior and posterior chamber- nutritive media for the lens and cornea


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The Orbits and Ocular Appendages

Bony Orbitscontains:

1) eyeball and their muscles

2) nerves and blood supply

3) levator muscle of the upper eyelid

4) lacrimal gland

5) lacrimal sac

6) fat as packing

7) a few nerves and vessels which pass through

Eyeball occupies 1/5th of the volume of the orbit


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Eyelids upper and lower mobile folds

2 sets of antagonistic musclesa) Orbicularis oculi

- closes the lids

- innervated by CN VII

- Bells Palsy/Bells phenomenon

b) Levator Palpebral Superioris

- opens/raises the lids

- innerrated by III CN- ptosis paralytic drooping of the eyelids


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Conjuctiva - transparent mucous membrane whichcovers the deep surface of the lids (palpebral) and theanterior surface of the eyeball (except the cornea),

bulbar conjuctiva

- gives the red eye

Lacrimal Gland - lies behind the upper and outerorbital margins

- watering of the eyes

a) overproduction1) local irritation

2) emotional stimuli

3) CN VII (crocodile tears)

salvary gland secretory fibers find their

way to the lacrimal glandb) faculty drainage

1) displacement of the lower lid

2) congenital, traumatic, inflammatory obstruction ofany part of the lacrimal passages


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Extraocular Muscles- 4 rectus / 2 obliques

- primary position / visual axis

- squint that condition in which the visual axis ofthe eye ( the squinting eye) is not

directed to the object being looked at by

the other eye (the fixing eye)


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Eye Examination by the General

Physician3 Reasons for Examining the Patients Eyes

1) Complaints by patients of symptoms which suggests some ocularabnormalities

- pain in the eye / seeing haloes around light in

glaucoma- blurring of vision cataracts

2) The fact that many ocular diseases and defects can be detectedbefore they give rise to obstructive symptoms (e.g. chronicglaucoma)

3) The fact that systematic diseases commonly have ocularmanifestations and these may lead to the recognition ofunsuspected disease e.g. retinopathy in symptomlessdiabetes; or they may help in the diagnosis of the systematicdisease e.g. choroidal tubercles in an undiagnosed fever orthey may help in the management of the systematic diseasee.g. retinopathy in hypertension


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Ocular Symptoms

- can be divided into 3 groups1) Altered function (visual symptoms)

a) Reduced Vision

1) Reduced central vision (impaired perception of form)

-manifested as a decrease in visual acuity2) Reduced peripheral vision (impaired perception of space)

-manifested as a defect in the visual field

(e.g. in glaucoma)

3) Impaired Vision in dim light (night blindness)(e.g. in retinitis pigmentosa)

4) Impaired Color perception (color blindness)


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b) Superimposed Visual Phenomena1) Floaters spots before the eyes of varying

shapes and sizes and are usually due to

opacities in the vitreous2) Haloes - colored rings encircling bright lights

- most common cause corneal edemasecondary to acute angle closure glaucoma

3) Photopsia - sensations of lights or luminouspatterns which are experienced when theeyes are closed

- in migraine

c) Diplopia double vision is experienced wheneverthe visual axes if both eyes are not directed to thesame object, provided that the vision of each eyeis reasonably good and binocular vision has beennormally developed


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2) Abnormal Sensation

- deep pain in the eye

- foreign body pain in the eye

- smarting, burning pain

- headaches

- photophobia

- watery eyes

- dry eyes

- contrary to popular opinion, ocular defects arenot a common cause of headaches

- migraine is not caused by refractive errors


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3) Altered Appearancea) Ptosis - drooping up the upper eyelid

- caused by CN II lesions, myasthemia giravisb) Ectropion drooping or eversion of the lower lid,brings patients because of the unsightliness,watering and discomfort

c) Retraction of the Upper Lid

- exposes a narrow rim of sclera above the cornea

- in thyroid disorders

d) Lagophthalmos

- inability to shut the lids completely- CN 7th lesions

e) Proptosis - unilateral protrasion of the globe

- results from orbital injury, inflammation or

tumors


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f) Exophthalmos bilateral protrusion of the eyes- due to thyroid disorders

g) Strabismus ( squint)h) Discharge - may be mucus or pus

- in conjuctivitis

i) Red rimmed eyes with crusting in blepharitis

j) Swelling in the lids from edema maybe due tonephrosis or local causes stye, insect bites

k) Localized swelling of the lid

- meibomian cyst / external hordcolum

l) Benign lid tumor papillomata- xanthelasma

m) Malignant lid tumor

- basal cell carcinoma (rodent ulcer)


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n) myokimia orbicularis spasmodic fine contractions

of part of an eyelid

o) Growth on the conjuctiva

1) Pinguecula small yellowish white lumps

adjacent to the cornea in the region

exposed to the palpebral opening

2) Ptyregium wing-shaped vascular thickening of

the conjuctiva

p) Arcus Senilis complete or incomplete white ring

encircling the cornea about from within thelimbus

q) Redness of the eye


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Trichiasis


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Localized Folliculitis


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Chalazion


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Internal Hordeolum


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External Hordeolum (sty)


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Xanthelasma


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Ulcerating squamous cell

carcinoma


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Cicatricial ectropion


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Cicatricial entropion


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Left ptosis


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Bilateral lid retraction


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Epicanthal folds


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External Examination

Visual Acuity

- most rewarding single test of ocular functionis the evaluation of visual acuity

- is a measure of the accuracy of form visionand in general usage visual acuity meansthe ability to distinguish the details andthe shape of objects

- it is a measure of the resolving power of theeye


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a) Distance Vision

- measured with a letter chart (Snellens), number chart,or E chart

- recording is as a fraction e.g. 20/30- numerator (20) represents the distance to the chart

- denominator (30) the distance which a normal eyecan read the line

thus, 20/30 means the patient is 20 ft. away and can reada line that a normal eye should read at 30 ft.

- record the results in the form

Vod = 20/30 Vos = 20/30

or if glasses wornVod with correction = 20/20 Vos with correction 20/20

for both eyes, record as Vo.u. = 20/20

if i i i l th 20/200 d t ti di t


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- if vision is less than 20/200, reduce testing distance15/200

- counting fingers (CF at 5 ft)

- hand movements (HM)

- light perception (LP)

- no light perception (NLP)

- uncorrected vision of less than 20/20 may be due to

a refractive error

- pinhole test is an easy and useful screening test for

retinal abnormality

Near VisionUse Jaegger chart

- In patients with reading difficulty (Presbyopia)


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Visual Field Tests

Limits of the visual fields

- 60 nasalward

- 50

upwards- 90 temporally

- 70 downwards

Confrontation testingUse to treat optic tract lesions


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NYSTAGMUS

Involuntary rhythmic oscillatory movement of the

eyes from side to side (Horizontal nystagmus) or

up and down (vertical)

Horizontal Nystagmus peripheral lesions

Vertical Nystagmus mid-brain, brain stem ofupper cervical cord


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INTRAOCULAR PRESSURETonometry - instrumental estimation of the IOP (slide)


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Visual Examination of Ocular Structures

A. General Observation

- observe whole patient and surroundings of the eye

- obvious changes which can be overlooked

1) abnormal head posture (head tilt)

2) exophthalmos or enophthalmos

3) ptosis or retraction of the upper eyelid

4) ectropion or entropion of the lower eyelid

5) incomplete closure of the lids

6) color of the iris


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Detailed inspection1. Lids

- lid examination has 3 objectivesa) to ascertain the adequacy of protection of the eyes

b) to seek signs that betray systemic disease

c) to detect local disease

- do the lids close completely (?)

- may lead to dry eye-infection

- in facial perolysis

- systemic diseases (nephrosis, heart failure, allergy, or thyroid

deficiency) may be suspected in the presence of lid edema

Hordeolum localized infection of the small glands above the

eyelashes

Chalazion infection or retention cyst of the meibonian gland

Ectropion vs. Entropion


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Lacrimal apparatus

- swelling, tenderness, regurgitation from the

punctum on applying pressure over the sac


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ConjunctivaPalpebral - lines the posterior surface of the lids

- cannot be seen until the lids are everted

- How to evert the eyelids

Examine for:1) hyperemia

2) discharge

3) foreign bodies


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Gonococcal Conjunctivitis


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Advanced Pterygium


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Conjunctival Hyperaemia


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Sclera- localized hyperemia with tenderness means episcleritis

- lacerations should be specifically looked for in injuries

Cornea

- 2 most common abnormalities are abrasions and opacities

Abrasion - best seen with 1% sterile flourescein drop (stain brilliant

yellow-green color)

look also for:

1) general loss of luster e.g. corneal edema

2) foreign bodies

3) grey spots or areas i.e. ulcers, infiltrate

4) vascularization


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Sectoral Episcleritis


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Pseudomonas Keratitis


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Dendritic Ulcer Stained w/ Flourescein


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Mucous Plaque Keratitis


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Corneal Abrasion w/ flourescein


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Corneal flap

Anterior Chamber


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Anterior Chamber- examine the depth

Hyphema - blood in anterior chamber

Hypopyon - pus in anterior chamber

Aqueous flares

Iris


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Iris

Iridodenesis - jelly-like tremulousness of the iris

on movement of the eye

Iridialysis - tearing of part of the peripheral

attachment of the iris to the ciliary body

Loss of color (heterochromia irides)

Large inferior iridodialisis

Pupils


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Pupils- perfectly round, equal in size, constrict visibly to lightand during accommodation

direct vs. consensual pupil reaction

e.g. monocular blindness

affected eye ----- (+) consensual

(-) directOpposite eye - consensual

Test for accommodation

- failure to react to light with preservation ofconvergence (Argyll Robertson pupil) is verycharacteristic of CNS syphilis

Pupil size


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p- normally smaller in infancy and old age

Anisocoria

- difference in pupil size

- in CNS Syphilis

Mydriasis

enlargement of the pupil due to:1) ocular injury

2) acute glaucoma

3) systemic poisoning by parasympatholytic drugs

4) local use of dilating drugs

Miosisconstriction of the pupil

1) in iritis

2) in glaucoma patients treated with pilocarpine

3) physiologically - during sleep


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Irregular pupils

1. in posterior synechiae (adhesions of pupil margins to lens capsule)2. in injury

3. in iridodialysis

Intraocular Pressure

- pressure measurement is important because elevated IOP known as

Glaucoma causes slow death of nerve fibers and is responsible for

12 % of blindness in the US

- finger tension

- tonometry


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Extraocular Muscles (EOMs)

- straightness of the eyes is most easily demonstratedby observing the reflection of light upon the cornea(should be symmetrical)

- an asymmetric light reflex will readily betray a

deviating eye- epicanthal folds in children - psuedostrabismus

- a paralyzed EOM may be one cause of oculardeviation

- muscle paralyses are best detected by moving theeyes into the six cardinal positions of gaze

- cover test determines whether the eyes are straight


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INSTRUMENTAL EXAMINATION OF THE EYE


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INSTRUMENTAL EXAMINATION OF THE EYE

A. Slit-lamp Biomicroscope

A low-power binocular microscope coupled with anilluminating system mounted on a table which alsohas a headrest to steady the patients head

B. Ophthalmoscopy- Red (-) numbers focus farther away;

Black (+) numbers focus nearer

- Optic disc - about 1.5mm in diameter (slide)


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Normal Fundus

Disc: outline layer; physiologicalcup as pale area centrally

Retina: Normal red/orange color,macula is dark avasculararea temporally

Vessels: Arterial venous ratio 2 to 3;the arteries appear a brightred, the veins a slightlypurplish color


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Hypertensive Retinopathy

Disc: outline clear

Retina: Exudates andflame hemorrhage

Vessels: attenuatedincreased arterialreflex


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Nonproliferative diabetic retinopathy

Disc: Normal

Retina: Numerous scatteredretinal exudates andretinal hemorrhages

Vessels: Mild dilation of retinalveins

Glaucomatous Cupping of disc


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Glaucomatous Cupping of disc

Disc: Margins sharp and clear;pale white color

Retina: Normal

Vessels: Arteries attenuated;veins normal


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Retinal detachment

Disc: Normal

Retina: Gray elevation in

temporal area withfolds in detachedsection

Vessels: Tortous and elevatedover detached retina


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Thank you


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SU School of

Medicine

PD Opthalmology

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