PATIENT DOCTOR II

OPHTHALMOLOGY

Rolando E. Regalado MD, FPCS EENT

Introduction
As a medical student, you are the physician of tomorrow as such you need to understand that the doctor is a medical detective. 2 most fundamental skills necessary for the medical investigation Interrogation and examination

Doctor Patient Relationship

the doctor must learn to conceal any moral judgements that he may have about the actions and attitudes of the patient, the physician should be moral but not a moralist genuine kindness and sympathetic understanding come only from within fortunately most medical students have more than a little compassion for their fellowmen, in fact, it is a powerful motivating factor in their selection of a career.

 But

that is the trick and glory of medicine. You must develop a kinship close enough to succor but not so close as to impair your objectivity or drain your emotions. You must identify with the wounded without feeling the pain; work with the wretched 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

Anatomy of the Eye

a) b)

c) a) b) c)

The Eyeball Hollow spheroid 25 mm in diameter Adult size reached by age of 3 Composed of 3 layers and 3 internal zones 3 layers Outer fibrons (cornea/sclera) Middle vasculomuscular (choroid, ciliary body and iris uvea or uveal tract) Inner neural layer (retina) 3 internal zones Aqueous Lens Vitreous

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

Cornea
by tear film gives cornea perfect mirror 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) total power of the eye (60D)
- covered

Middle Layer
Choroid vascular layer Ciliary Body band 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)

Inner Layer
Retina - 0.4 mm thick
- lines interior 2/3rds of the globe - consists of pigment epithelium inaternall and transparent 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

Optic Nerve axons of the garglion cells is a direct

extension of the brain

Lens - 9 mm diameter
- 5 mm thick - biconvex - size increases with age - provides the adjustable part of the eyes reflective power

Vitreous Body - transparent avascular jelly which

fills the posterior segment of the globe behind the lens - 98 % water

Aqueous Humor - clear liquid similar in

composition to protein-free plasma and fills the anterior and posterior chamber - nutritive media for the lens and cornea

The Orbits and Ocular Appendages

Bony Orbits
contains: 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

Eyelids upper and lower mobile folds

2 sets of antagonistic muscles a) 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

Conjuctiva - transparent mucous membrane which

covers the deep surface of the lids (palpebral) and the anterior surface of the eyeball (except the cornea), bulbar conjuctiva - gives the red eye

Lacrimal Gland - lies behind the upper and outer

orbital margins - watering of the eyes a) overproduction 1) local irritation 2) emotional stimuli 3) CN VII (crocodile tears) salvary gland secretory fibers find their way to the lacrimal gland b) faculty drainage 1) displacement of the lower lid 2) congenital, traumatic, inflammatory obstruction of any part of the lacrimal passages

Extraocular Muscles
- 4 rectus / 2 obliques - primary position / visual axis - squint that condition in which the visual axis of the eye ( the squinting eye) is not directed to the object being looked at by the other eye (the fixing eye)

Eye Examination by the General Physician

3 Reasons for Examining the Patients Eyes
1) Complaints by patients of symptoms which suggests some ocular abnormalities - 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 detected before they give rise to obstructive symptoms (e.g. chronic glaucoma) 3) The fact that systematic diseases commonly have ocular manifestations and these may lead to the recognition of unsuspected disease e.g. retinopathy in symptomless diabetes; or they may help in the diagnosis of the systematic disease e.g. choroidal tubercles in an undiagnosed fever or they may help in the management of the systematic disease e.g. retinopathy in hypertension

Ocular Symptoms
- can be divided into 3 groups
1) Altered function (visual symptoms) a) Reduced Vision 1) Reduced central vision (impaired perception of form) -manifested as a decrease in visual acuity 2) 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)

b) Superimposed Visual Phenomena 1) Floaters spots before the eyes of varying shapes and sizes and are usually due to opacities in the vitreous 2) Haloes - colored rings encircling bright lights - most common cause corneal edema secondary to acute angle closure glaucoma 3) Photopsia - sensations of lights or luminous patterns which are experienced when the eyes are closed - in migraine c) Diplopia double vision is experienced whenever the visual axes if both eyes are not directed to the same object, provided that the vision of each eye is reasonably good and binocular vision has been normally developed

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 are not a common cause of headaches - migraine is not caused by refractive errors

3) Altered Appearance a) Ptosis - drooping up the upper eyelid - caused by CN II lesions, myasthemia giravis b) 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

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 to nephrosis 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)

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 the limbus q) Redness of the eye

Trichiasis

Localized Folliculitis

Chalazion

Internal Hordeolum

External Hordeolum (sty)

Xanthelasma

Ulcerating squamous cell carcinoma

Cicatricial ectropion

Cicatricial entropion

Left ptosis

Bilateral lid retraction

Epicanthal folds

External Examination
Visual Acuity - most rewarding single test of ocular function is the evaluation of visual acuity - is a measure of the accuracy of form vision and in general usage visual acuity means the ability to distinguish the details and the shape of objects - it is a measure of the resolving power of the eye

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 eye can read the line thus, 20/30 means the patient is 20 ft. away and can read a 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 worn Vod with correction = 20/20 Vos with correction 20/20 for both eyes, record as Vo.u. = 20/20

- if vision is less than 20/200, reduce testing distance 15/200 - 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 Vision
Use Jaegger chart
- In patients with reading difficulty (Presbyopia)

Visual Field Tests

Limits of the visual fields - 60 nasalward - 50 upwards - 90 temporally - 70 downwards Confrontation testing Use to treat optic tract lesions

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 of upper cervical cord

INTRAOCULAR PRESSURE
Tonometry - instrumental estimation of the IOP (slide)

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

Detailed inspection
1. Lids - lid examination has 3 objectives a) 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

Lacrimal apparatus
- swelling, tenderness, regurgitation from the punctum on applying pressure over the sac

Conjunctiva
Palpebral - 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

Gonococcal Conjunctivitis

Advanced Pterygium

Conjunctival Hyperaemia

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 i.e. ulcers, infiltrate

2) foreign bodies 3) grey spots or areas 4) vascularization

Sectoral Episcleritis

Pseudomonas Keratitis

Dendritic Ulcer Stained w/ Flourescein

Mucous Plaque Keratitis

Corneal Abrasion w/ flourescein

Corneal flap

Anterior Chamber
- examine the depth Hyphema - blood in anterior chamber Hypopyon - pus in anterior chamber Aqueous flares

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
- perfectly round, equal in size, constrict visibly to light and during accommodation

direct vs. consensual pupil reaction e.g. monocular blindness affected eye ----- (+) consensual (-) direct Opposite eye - consensual
Test for accommodation - failure to react to light with preservation of convergence (Argyll Robertson pupil) is very characteristic of CNS syphilis

Pupil size
- 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

Miosis
constriction of the pupil 1) in iritis 2) in glaucoma patients treated with pilocarpine 3) physiologically - during sleep

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

Extraocular Muscles (EOMs)

- straightness of the eyes is most easily demonstrated by 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 ocular deviation - muscle paralyses are best detected by moving the eyes into the six cardinal positions of gaze - cover test determines whether the eyes are straight

INSTRUMENTAL EXAMINATION OF THE EYE

A. Slit-lamp Biomicroscope

A low-power binocular microscope coupled with an illuminating system mounted on a table which also has 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)

Normal Fundus
Disc: Retina: outline layer; physiological cup as pale area centrally Normal red/orange color, macula is dark avascular area temporally

Vessels: Arterial venous ratio 2 to 3; the arteries appear a bright red, the veins a slightly purplish color

Hypertensive Retinopathy
Disc:
outline clear

Retina: Exudates and

flame hemorrhage

Vessels: attenuated
increased arterial reflex

Nonproliferative diabetic retinopathy

Disc: Retina:

Normal Numerous scattered retinal exudates and retinal hemorrhages

Vessels: Mild dilation of retinal veins

Glaucomatous Cupping of disc

Disc:

Margins sharp and clear; pale white color

Retina: Normal

Vessels: Arteries attenuated; veins normal

Retinal detachment
Disc: Normal

Retina: Gray elevation in temporal area with folds in detached section Vessels: Tortous and elevated over detached retina

Thank you

SU School of Medicine