Chapter 1 Eye History and Physical
Chapter 1 Eye History and Physical
Chapter 1 Eye History and Physical
OPHTHOBOOK-CHAPTERS
18:22
Family History:
Focus on history of glaucoma and blindness.
Patients will often confuse glaucoma with
cataracts, so be sure to clarify the difference.
Allergies:
List basic allergies and their reaction. We
sometimes give Diamox to control eye pressure so
make sure your glaucoma patient isn’t allergic to
sulfa drugs.
Medications:
Find out what eyedrops your patient is taking, and
why. Are they using a regular eyedrop? How about
vasoconstricting Visine? Did they bring their
drops with them? If your patient can’t remember
their medications, it often helps to ask about the
bottlecap-color of their drops (ex. all dilating
drops have red caps). Also, it’s nice to know if
your patient is taking an oral beta-blocker already,
in case you want to start a beta-blocking eyedrop.
Visual Acuity:
You measure visual acuity with a
standard Snellen letter chart (the
chart with the BIG E on it). If your
patient can’t read the E on the top
line, see if they can count fingers at different
distances. Failing this, try hand motion and light.
Poor distance vision usually occurs from
refractive error (your patient needs better
glasses).
Das Pinhole!
A quick and easy
way to determine
whether refraction
is the culprit, short
of actually testing
different lenses, is
with the pinhole
test. Punch a small
hole in a paper
card, and have your patient reread the eye-
chart while looking through this pinhole. This
can actually improve vision by several
diopters. It works because the paper blocks
most of the misaligned rays that cause visual
blur, and allows the central rays to focus on
the retina. If your patient shows no
improvement with pinholing, start thinking
about other visual impediments like cataracts
or other media opacities. Most occluders (the
black plastic eye cover used during vision
testing) have a fold-down pinhole device for
this purpose.
Near Vision
Near vision can be assessed with a near-card or
by having your patient read small print in a
newspaper. Don’t try using the near-card to
estimate distance acuity as distance vision is
quite different than close-up acuity. That 20/20
marking printed on the near-card only checks
“accommodated” near-vision. Remember that
older patients can’t accommodate well and need
a plus-power lens (reading glasses) to help them
read the card. Carry a +2.50 lens with you when
seeing older inpatients as most of these patients
leave their reading glasses at home. We’ll cover
accommodation and presbyopia in greater detail
later in the optics chapter.
Pupils:
The pupils should be equally round and
symmetric with each other. You can test reactivity
to light with a penlight, but a brighter light like the
one on the indirect ophthalmoscope will work
much better. When testing the eyes, you will see a
direct constriction response in the illuminated
eye, and a consensual response in the other eye.
These should be equal and synchronous with
each other. Also, check the pupils with near-
vision, as they should constrict with
accommodation.
Pressure:
We measure pressure by determining how much
force it takes to flatten a predetermined area of
the corneal surface. There are several ways to do
this and in the ophthalmology clinic we use the
“Goldman Applanation Tonometer” that is
attached to the slit-lamp microscope.
Confrontational Fields:
All patients should have their visual fields
(peripheral vision) checked. A patient may have
great central vision, with perfect eye-chart
scores, but suffer from “tunnel vision” resulting
from neurological diseases or glaucoma. Your
patient may not even be aware of this peripheral
visual loss if it has progressed slowly over time.
EOMs (extraocular
movements):
Check extraocular movements by having your
patient follow your fingers into all quadrants. If the
patient has decreased mobility in an eye from
nerve paralysis or muscle entrapment, you may
notice this from casual inspection or by more
sophisticated cover/uncover tests. More often,
though, you won’t see anything but your patient
will, complaining of double vision.
Seeing Double?
When evaluating double vision, you must first
determine whether the doubling is monocular
or binocular.
Cornea (K):
Look at the corneal surface for erosions and
abrasions that might indicate trauma. Does
the stroma look clear? Look at the back
endothelial surface for folds or gutatta
bumps. Fluorescein dye will make surface
abrasions easier to spot.
Iris (I):
Make sure the iris is flat and the pupil round. If
the patient has diabetes or an old retinal
vascular occlusion you should comment
whether you see any signs of
neovascularization of the iris.
Lens
(L):
Is the
lens
clear, or
hazy
with
cataract
? Are
they phakic (they have their own lens),
pseudophakic (prosthetic lens), or aphakic
(no lens at all)?
Vitreous (V):
You can look behind the lens into the dark
vitreous cavity. If you suspect a retinal
hemorrhage or detachment, you may see cells
floating here.
Fundus Exam:
The fundus is the only place in the body where
you can directly visualize blood vessels and
nerves. In our notes we typically comment on four
retinal findings:
At the slit-lamp
The best way to look at the posterior fundus in
magnified detail is with a lens at the slit-lamp.
This is how we look at the optic nerve and macula
in the clinic, but it takes practice. We use smaller,
more powerful lenses such as a 90-diopter lens.
PIMP QUESTIONS
1. What are the three “vital signs of
ophthalmology” that you measure with every
patient?
Vision, pupil, and pressure. Some
ophthalmologists might say there are five vital
signs (adding extraocular movements and
confrontational fields.) It’s important to check
these signs prior to dilation as dilating drops will
affect these measurements.
M (macula)
V (vessels)
P (periphery)
D (disk)
Timothy Root, MD
61 Comments
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Srini says:
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Hend says:
To corinne,
about Ur question…… answer is….he can
see 20/25 & 3(letters) from next line of
chart but not 20/20 !
also if he see 20/25 except 3(letters)
written as 20/25-3
Hend
genior resident
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gr8 book
thanks sir
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Nima says:
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sopheak says:
Thanks.
Best regards,
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Sally says:
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rozlin says:
just love it
simple, easy to understand…
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Mo says:
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Loretta says:
What does is mean by “fundus not
visualized”? Is this a normal or abnormal
finding?
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Raju G says:
Thank you
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