OPHTHALMOLOGY©POKEMONMDTRANSES

BASICEYEEXAMINATION
FEUNRMFBATCH2019-20233RDYR1ST SEM|ADASTRAPERASPERA

VISUAL ACUITY TESTING Alternative Notations for Recording Distance VA

• Fundamental element of the basic eye examination
• Assess the function of the fovea centralis
• It should be done prior to any manipulation of the eye

Fovea Centralis – Center of the eye that has the Highest visual acuity

Distance VS Near Visual Acuity

Distance VA for all patients including children
For patients over 35 years of age, in cases DVA is difficult to
Near VA
perform or not possible (bedside)

❖ Snellen’s Chart – most commonly used; some charts use same

number of letters per row as compared to Snellen’s chart. *English system is commonly used; decimal and LogMar for research purposes*
❖ Tumbling E Chart and Landolt Broken Ring – used for children and
the illiterate; ask for the patient to point the direction; DISTANCE VISION
❖ Picture chart – for kids • Patient unable to see the largest letter on the Snellen (20/200)
• Goal is for the patient to see the letter E.
How to test the Vision?
SNELLEN CHART TUMBLING-E PICTURE CHART Example:
If patient can read it in 15 feet, then you put 15/200.
If at 10 feet, patient can read EFP in Snellen, then patient might be able to see
better so try 15 feet.

Use the following methods if the patient is UNABLE TO READ THE E

1. Bring the patient closer to chart until he/she is able to read the 20/200 line
2. If unable to read 20/200 line at 3 feet, do Counting Fingers (CF). Do one time
at a time.
3. If unable to count fingers, determine if patient can distinguish presence of
absence of Hand Movement (HM)
4. If cannot detect HM, use penlight to determine if patient can correctly detect
the direction of the light source Light Projection (LPj) by directing light in 4
Standard distance of a patient from the chart is 6 meters or 20 feet directions
1. Patient 20 ft or 6 meters from a well illuminated Snellen Chart ❖ Good LPj – 4 quadrants
2. Instruct patient to occlude one eye using an opaque occlude or his/her palm; ❖ Fair LPj – 2-3 quadrants
to avoid confusion, usually right eye first ❖ Poor LPj – 1 quadrant
3. Patient read chart starting at the first line until the smallest line that he/she 5. If patient unable to correctly identify the direction of the light source but able
can distinguish more than half of the figures to detect the presence, record the patient visual acuity as Light Perception (LP)
4. Record visual acuity
5. Instruct the patient to occlude his/her other eye and repeat steps 3 and 4 *Always do these methods with one eye occluded*
*A patient with no LP means he/she is clinically blind (NLP)*
VISUAL ACUITY (VA) = ____Distance of the patient from the chart______
Distance at w/c normal eye can read the given line SNELLEN’S INDEX DEFINITION PRACTICAL TEST
Example: NLP Cannot see light Clinically blind
• VA = 20/60 (Patient can see at 20 feet what a person with normal visual acuity LESS THAN 3/200 Hand movement Can recognize form and
can see at 60 feet) motion at 1 m
• Patient can read Snellen Chart until 6th row: VA = 20/30 LESS THAN 10/200 Travel vision Cannot read headlines
• Patient got 1 wrong letter in 5th row, but got all the 6th row letters LESS THAN 20/200 Minimal reading Can read headlines but not
correct: VA = 20/40 14-point type
• Patient can only read one letter in 8th row: VA = 20/25 + 1 since she got one MORE THAN 20/200 Partial seeing Read 14-point type with
letter correct in the 8th row BUT LESS THAN 20/70 marked difficulty

Visual Acuity in Diopters Pinhole test

• If the Patient’s VA is <20/20 in either eye, perform pinhole test is to
This graph shows the determine if the vision is due to an uncorrected refractive error
relationship of the error of • Measures visual acuity with the patient viewing the test symbols through a
refraction in diopters and small opening/s in an opaque
visual acuity. The higher the • Allows the central ray to be focused on the center of the eye altering
grade in diopters in EOR, the visual refraction
lesser the uncorrected visual • If vision is improved by pinhole, there is an error of refraction (+)
acuity. hydropia/myopia/astigmatism

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Pathologic lead eversion
NEAR VISION

A lot of times, foreign body can

be trapped under it. In the pic
there is a foreign body
embedded on the conjunctiva
and very difficult to remove.

EXTERNAL EYE EXAMINATIONS

• Done to assess pupillary reaction
• Check for clarity
• Near vision charts contain numbers, letters or figures in different sizes
designed to subtend an angle of 5 minutes at various distances How to Undergo Pupil Examination
❖ Assess the pupil size and shape
Jeager notation – used to grade near vision ❖ Assess the pupil reaction to light by Direct pupillary reaction and
Example: 7 yo - start of perfect vision Consensual pupillary reaction
❖ J1 = able to read small texts ❖ Assess the reactions of the pupil to a swinging flashlight test
❖ J3 = able to read normal texts
• Standard test distance – 14 inches (35 cm) Swinging Penlight Test - Test used to check for relative afferent pupillary
• Record the size and distance of the smallest figures read defect
Abbreviations used in recording VA

Example:
❖ DVA-OD = 20/20
Distance visual acuity of the right eye is graded 20/20
❖ NVA = J1 AFFERENT PUPILLARY DEFECT
Near visual acuity is graded J1 able to read small texts • Pupillary reactions measured in dim light
❖ DVA-OS = 20/60 ❖ Record response to direct illumination, a near target and the
Distance visual acuity of the left eye is graded 20/60 presence of an afferent pupillary defect (APD)
❖ DVAcc-OD = 20/20 • An APD indicates injury in the afferent pathway, found with optic nerve
Distance visual acuity of the right eye is 20/20 corrected with eyeglasses injuries
❖ DVA Pinhole OD = 20/20 ❖ Contusion
Distance VA of the right eye is 20/20 via pinhole ❖ Avulsion and transection
❖ Retinal injuries such as commotio retinae, retinal detachment
GROSS EXAMINATION OF THE EYE ❖ Major vitreous hemorrhage
• Assess the position of the eyes in relation to other facial structures
• Symmetry between two eyes
• Take note of the presence of redness, masses or abnormal pigmentation,
discoloration on the eyelids, and periocular tissue
• Eyelashes should be directed outward
• Inspect the lids, palpebral fissure, and surrounding tissues

Eversion of the Upper Eyelid Eversion and of the Lower Lid respectively

*Use a cotton tip to evert the upper eyelid*

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In the pic, you can see that the right eye is bulging and relatively swollen than Indications
the other eye at external eye exam. This is a case of proptosis seen as ❖ High power study of disc and macula
asymmetry of both eyes, the position of the lids is not the same, there is more ❖ Measure elevations/depressions
sclera shown on external exam of the right eye. On worm’s eye view, the right ❖ Measure diopteric power of eye
eye is protruding. Upon imaging there is an enlargement of the extraocular ❖ Study of small lesions
muscles. This can be seen in a THYROID EYE DSE manifested in GRAVE’S DSE. ADVANTAGE DISADVANTAGE
Upon cross-sectional cut, there is a fusiform enlargement of EM’s
•High magnification •Small field 10-12D
•Erect image •Poor illumination
OCULAR ALIGNMENT AND OCULAR MOTILITY TESTING •Measurement capabilities •Monocular
OCULAR ALIGNMENT AND STRABISMUS (elevations/ depressions/ size) •Distortion near periphery
Hirschberg Test – you shine a light in front I •Easy to learn
of the patient’s eye and observe where the
corneal light reflex will fall. If it is at the
Steps in Performing Direct Ophthalmoscopy
center, then it is aligned, if it is not in the
❖ Have the patient comfortably seated. With the room lights
center, then there is already a problem in 1
dimmed, instruct the patient to look straight ahead while trying not
ocular alignment
to move the eyes
❖ Set the focusing wheel of the ophthalmoscope at 0. Set the
OCULAR MOTILITY TESTING
aperture wheel to select the large round white light
• Version – eye movement tested with both
❖ Begin to look at the right eye about 1 foot from the patient. Use

:
eyes open
your right eye with the ophthalmoscope on your right hand. When
• Ductions – one eye at a time is tested
you look at the patient’s line of sight at the pupil, observe the red-
orange reflex
*Move the examiner’s finger in an H
❖ Place your freehand on the patient’s forehead or shoulder to keep
pattern and note for asymmetry of
yourself steady and to aid your proprioception
movement*
❖ Slowly come close to the patient at an angle of about 15 degrees
temporal to the patient’s line of sight
ESOTROPIA Inward Light reflection appears displaced
misalignment laterally in the non-fixating eye
*NEVER shine the light directly to the center of the eye or else the pupils will
EXOTROPIA Outward Light reflection appears displaced constrict. The temporal angle is done so that you will be shining the light on
misalignment medially in the non-fixating eye the blindspot of the eye*
HYPOTROPIA Downward Light reflection appears displaced
displacement superiorly in the non-fixating eye ❖ Try to keep the pupil in view. Turn the focusing wheel of the
HYPERTROPIA Upward Light reflection appears displaced ophthalmoscope to bring the patient’s retina to focus
displacement inferirly in the non-fixating eye ❖ When the retinal vessels come into view, follow it as it widens the
optic disc, which lies nasal to the center of the retina
INTRAOCULAR PRESSURE DETERMINATION ❖ Examine the optic disc, retinal vessels, retinal background, and the
Intraocular Pressure (IOP) macula
❖ Refers to the pressure that is created within the closed environment ❖ Repeat the steps on the patient’s left eye, holding the
of the eye ophthalmoscope with your left hand and viewing with your left eye
❖ Governed by a balance between the production and aqueous humor
and its drainage INDIRECT OPHTHALMOSCOPY
❖ Vary from individual to individual and exhibits normal fluctuations • Less magnified but wide field
during the day panoramic view of the eye is
*Normal IOP is 10-21 mmHg* obtained up to 35 degrees
• Provides a binocular manner
TANOMETRY
A, – used to measure IOP of viewing the eye

Methods commonly used for determining IOP levels are the following: Indications
1. Finger Palpation – palpate globe if it is hard (high IOP), ❖ Presence of media
soft (low IOP); only a rough estimate. Most Basic way to test for IOP opacities
2. Indentation Tonometry – uses Schiotz tonometry to indent the center of the ❖ High refractive errors
cornea, done under anesthesia ❖ Children eye exams
3. Applanation Tonometry – gold standard; disadvantage ❖ Total fundus
is it uses special equipment examination
❖ Examination of large
DIRECT OPHTHALMOSCOPY lesions
•Manipulation of an
Ophthalmoscope is required
used to view the eye in a ADVANTAGES DISADVANTAGES
Monocular manner •Wide field 30-35D view anterior to •Low magnification 2-5x
• Technique where one is to equator possible • Inverted image
view the eye by direct close •Strong illumination •Difficult to learn
approach to the patient’s •Stereopsis
eye which only give a limited
field of view of only 10-12
degrees
• Highly magnified patient’s
eye but limited field

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FUNDUS EXAMINATION
• There are 5 structures that should be observed in a
systematic fundus examination:
❖ Optic media cornea, crystalline lens, and aqueous fluid
❖ Optic disc
❖ Retinal vasculature
❖ Retinal background
❖ Macular area

CUP-TO-DISC RATIO

The cup is the white pallor ring at the center of the optic disc and you
compare its size to the entire disc itself. The normal value is around 0.3-
0.4. This optic cup size is about 40 percent of the entire disc

AV RATIO

Comparison of the veins and arteries in terms of diameter the whiter

pinkish lines are the arteries while the bigger redder parts are the veins.
Veins are supposed to be bigger than the arteries because of its muscular
layer normal value is of 2:3.