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The Basic Ophthalmic Assessment

The Basic Ophthalmic Assessment. NPAA conference June 2, 2013 Dr. Jennifer Hodges. Outline. History Physical exam Visual acuity Eye movements Pupils Visual fields Intra-ocular pressure Visual exam / slit lamp. History. HPI Symptoms Vision loss? Diplopia ? Pain? Discharge?

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The Basic Ophthalmic Assessment

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  1. The Basic Ophthalmic Assessment NPAA conference June 2, 2013 Dr. Jennifer Hodges

  2. Outline • History • Physical exam • Visual acuity • Eye movements • Pupils • Visual fields • Intra-ocular pressure • Visual exam / slit lamp

  3. History • HPI • Symptoms • Vision loss? Diplopia? Pain? Discharge? • Trauma? • Time course, evolution • Monocular vs binocular • Past ocular history • Drops, surgery or prior trauma • Family history • Medications and allergies

  4. Visual Acuity1 • Snellen chart • 20 feet / 6 meters • Glasses • Pinhole • Encouragement!! • Near acuity • Reading glasses if >40-50 yo • App

  5. Eye Handbook2

  6. Eye Movements • Important if diplopia • Check if aligned in straight ahead • Corneal light reflex • Cover, uncover; cross-cover • Check in 8 positions (up, down, left, right, diagonals) • Look for limitation of movement

  7. Pupils3 • Direct response to light • Consensual response to light • Relative afferent pupillary defect (RAPD)

  8. Red Reflex4 • Check in all newborns, well baby/peds checks

  9. Visual Fields5 • Confrontational fields • Close mirror image eye to patient • Patient focuses on your open eye • Fingers equidistance between you and patient • Test 4 quadrants

  10. Intra-ocular Pressure6 • Symptoms of high pressure • Nausea and vomiting • Pain (ocular, chest, abdominal) • Mid-dilated pupil • Red eye • Tonopen

  11. Visual Exam7-9 • Lid swelling, erythema, proptosis • Conjunctiva • Injection • Peri-limbalvs diffuse • Bright red vsviolaceous/beefy • Discharge • Cornea • Fluorescein • Abrasion, foreign body, ulcer • Sidel sign / laceration • Anterior chamber • Hyphema, iris trauma, peaked pupil • Hypopion • Fundus – rule out disc swelling

  12. Framework for Common Ophthalmic Problems NPAA conference June 2, 2013 Dr. Jennifer Hodges

  13. Outline • Schemes of common problems • Acute vision loss • Red Eye (traumatic/non-traumatic) • Highlight of 15 ocular conditions • 7 Common • 8 Emergent • Consulting ophthalmology

  14. Acute visual loss Only 1 eye affected? Both eyes affected? Unilateral Bilateral Retina clear orswollen optic nerve disc? Other Complete/partialhomonymoushemianopia Retinal/choroid Pre-retinal Optic nerve/tract MigraineSystemichypoperfusion See Trauma / red eye Formal visualfield testingCT imaging Floaters +flashing lightsPeripheral blackcurtain-like lossof vision Central vision loss?Distortion? Sudden visual loss?Painless? -Infarct-Bleed-Other Red eye?N + V?Painful?Fixed pupil? IOP? Acute angleclosure glaucoma Age-related maculardegeneration Retinal / macularvascular Retinal tear / detachment Primary vs. secondary Central vision ?Loss of color vision?RAPD?Progresses over days? -Idiopathic-MS-Post Venous occlusion Arterial occlusion Demyelinating Small areacentral vision loss Peripheral ± centralvision loss Cherry red spot Painless?Elderly?HTN?DM? Non-arteritic Anterior ischemicoptic neuropathy Cilioretinal arteryocclusion Peripheral RAO Central RAO Elderly with newheadacheJaw claudication Temporal arteritis

  15. Posterior Vitreous DetachmentRetinal Tear/Detachment10-12 • Flashes/Floaters = PVD • Call within 24hrs, Triaged within 1 week • Ophthalmology to r/o retinal tear (15%) • Black Curtain = RD • Can come from any direction • Stays fixed (does not come and go) • RFs: myopia, surgery, trauma, age • Triaged: First thing in am/same day • NPO after midnight

  16. Loss of Vision – Seconds13, 14 • Normal (anterior) exam • Retinal Vascular Event • Rule out Giant Cell Arteritis (CRAO, AAION) • Sxs: HA, tenderness over temporal artery, scalp pain, fatigue, myalgias, PMR • CBC (plts), ESR (female: (age+10)/2, males: age/2), CRP • Emergency – requires urgent ophthalmic assessment and high dose steroids • Optic Nerve vascular event (NAION, AAION) • AmaurosisFugax • Warning stroke

  17. Acute Angle Closure Glaucoma15 • Red, painful eye • Nausea, vomiting • +/-chest, abdo pain • Mid-dilated pupil •  IOP • Hazy Cornea • Shallow anterior chamber • Treatment: Ophthalmology, lower IOP

  18. Red Eye (Traumatic causes) Surface Injury Blunt Trauma Globe Penetrating Injury • Wound self-sealing or not? • Retained intraocular foreign body or not? • Associated ocular injuries or not? UV exposure? Contact lens? Fingernail? Tree branch? UV Keratitis Chemical Injury • Acid • Alkali Corneal Abrasion • Up-gaze limitation (entrapment of inferior rectus) • Periorbital ecchymosis • Enophthalmus • (eye sunken back into socket) • Infraorbital nerve neuropraxia Blood in theanterior chamber Check IOP Imaging Other Potential Injuries • Cataract • Iridodialysis • Scleral rupture • Traumatic mydriasis • Choroidal rupture • Optic neuropathy • Retinal tears • Retinal detachment Hyphema Orbital rim or mid-facialbony fracture includingoptic canal fracture Orbital floor fracture

  19. Abraison16 • Painful!!! • Topical anesthesia facilitates exam (VA) • Fluorescein • Etiology • Trauma • Recurrent Cornea Erosions • First thing in am • Irritated for a few days • Treatment: • Polysporin eye drops/ointment QID • Ciprofloxacin eye drops QID (vegetable matter) • Vigamox/Zymar eye drops QID (contact lens wearer)

  20. Hyphema17 • Traumatic • Vision better after upright for awhile • Check IOP • Treatment • Keep head of bed elevated • Shield (avoid trauma) • No NSAID/ASA • Activity restriction

  21. Metallic Foreign Body18 • Etiology: Grinding/welding, non-traumatic ***Make sure there is no chance of ruptured globe • Vertical abraisons - f.b. under the lid? • High velocity (including welding)? • Orbital X-ray – r/o orbital/intraocular f.b. • Trmt: Remove, Abx QID X 4/7 until epithelial defect resolved

  22. Chemical Injury19 • Emergency • Minimal history and exam to rule out ruptured globe then – FLUSH, FLUSH, FLUSH • Topical anesthesia • Use speculum and Morgan lens if available • If not, hold eye open and drip in NS with IV tubing • Stop when pH = 7-7.5 • check other eye if unilateral • Urine dipstick if no pH strips • Ophtho consult, Abx ointment QID (Polysporin)

  23. Globe Rupture20-21 • Full thickness break in the eye wall • Can happen with sharp/blunt trauma • Especially be wary when pt has had prior ocular surgery • Signs: • 360 degrees subconj hemorrhage • Peaked pupil • Brown (uveal) tissue on surface of eye • Sidel sign • Flat anterior chamber • Any IOP, but especially really low • Mgmt: Shield, NPO, Ophtho for surgical repair

  24. Retrobulbar Hemorrhage22 • Etiology: Trauma, retrobulbar anesthesia • Classic hx: hx of trauma but vision fine… then sudden ++ pain, loss of vision, RAPD, high IOP, tight orbit, proptotic eye • Emergent – Canthotomy, Cantholysis • If we cannot get there in 15 mins, we will talk you through this over the phone

  25. Red Eye(Non-traumatic classified by diagnoses) Urgent (need to rule out / treat immediately) Non-urgent 1-Photophobia 2-Cells + flare (protein) in anterior chamber Ciliary flush Posterior synechia 1-Pain Tearning 2-Swelling + tenderness of lacrimal sac (medial side) 1-Severe pain Loss of vision Nausea 2- IOP Corneal edema Vomiting 1-Erythema and induration of skin 2-Superficial skin laceration or sinus pathology 1-Severe pain 2-Associated with collagen vascular and immune diseases 1-Pain Blurry vision 2-Breakdown of corneal epithelium White infiltrate Iritis Pre-septal / orbitalcellulitis Scleritis Dacrocystitis Corneal Ulcer Acute angleclosure glaucoma Skin/orbital infections from local extension Non-infectious Infectious • Collagen vascular disease • HSV (dendrite) • Bacterial (discharge) Erythema / scurf of lid margin Confluent / dependent blood under the conjunctiva Burning,scratchy eye Blepharitis Meibomian gland dysfunction Conjunctivitis Episcleritis Subconjunctivalhemorrhage Dry eye Corneal • Toxic changes (drops) • Punctate keratitis • Erosion • Contact lenses • Stye • Chalazion • Meibomitis Purulent discharge Itchy, watery,discharge 1- Symptoms 2- Signs Infectious Allergic Immunologic • Viral • Bacterial • Other

  26. Viral Conjunctivitis23 • “Pink eye” due to adenovirus • Classic story • Unilateral then ~24hrs later, bilateral • Infectious contacts • Watery discharge • lasts 7-14 days • Trmt – supportive (Put artificial tears in fridge, cool compresses) • Differences with bacterial conjunctivitis • Usually unilateral • Much more prominent pussy discharge *** Treat with Abx if significant pussy discharge. If the classic story, resist the urge to treat (just increasing Abx resistance!) and no need to see ophtho (concern if decreased VA, >14days, concerned another diagnosis etc.) ***If started on gentamycin (or other Abx) and still present at 7-14d, try stopping the Abx – frequent allergies to eye gtts

  27. Iritis7 • Autoimmune inflammation of the iris causing WBC and protein to leak into the anterior chamber • Symptoms – photophobia, (+/-dec vision), red eye, no pussy discharge • Signs – perilimbal flush (beefy red, angry) • Mgmt – Ophtho within 24 hrs ***Beware in any patient with Ankylosingspondylitis, Psoriatic arthritis, Crohns/UC, Reactive arthritis – this is not conjunctivitis!!!

  28. Sub-conjunctival Hemorrhage24 • Etiologies: Idiopathic, Valsalva, Traumatic, Blood thinners • Dramatic looking, but not harmful – check BP • Pearls – if conj elevated, lubricate! • No need for ophthalmology to see unless you are worried about (eg. Part of a trauma / associated with loss of vision)

  29. Pre-septal / Orbital Cellulitis25-26 • Infection – bug bite/break in skin, sinusitis, otitis media • CT orbits (Not just a CT head) • Orbital cellulitis – requires urgent trmt (Admission, IV Abx, +/- abscess drainage)

  30. Corneal Ulcer27 • Risk factors – contact lens wearer, abraison, trauma • White opacity with overlying epithelial defect • Check with fluorescein – if doesn’t stain overtop, think about scar / healing ulcer • Measure size (cornea 10mm across, pupil often 2-3mm… use to estimate) • Size important for triaging for ophthalmology • 1-2mm, outside of visual axis –vigamox/zymar q1h, see next day • >1-2mm, within visual axis – see immediately, admit

  31. Endophthalmitis28 • *** Beware in any post-ocular surgery patient • Most commonly 3d – 6wks after cataract sx • Can also occur from endogenous infection (eg. candidemia), post trauma • Sxs/signs – • pain • decreased vision • red eye • hypopyon (WBC in anterior chamber settle at bottom – can also cause obscuration of iris details)

  32. Eyes misaligned? Misalignment when eyesare not working together (latent deviation) Misalignment occurs wheneyes are working together (manifest deviation) Strabismus Phoria Tropia Is the deviation the samein all fields of gaze? Cover-uncover test(look at ipsilateral eye) No Yes Eye moves frommedially to straightahead when unvovered Eye moves fromlateral to straightahead when uncovered Non-paretic (comitant) Paretic (non-comitant) Esophoria Exophoria Strictly horizontal? Cover test(look at contralateral eye) No Onset 2.5-4yr Hyperopicusually When cover one eye, other eyemoves from mediallyto straight ahead When cover oneeye, other eyemoves from laterallyto straight ahead • Eye down + lat. • Ptosis • pupil involvment When lookingmedially, eyecannot depress Yes Eye cannotabduct Accomodative esotropia Congenital Esotropia Exotropia CN III problem CN IV problem CN VI problem

  33. Diplopia • Questions to ask your patient with double vision • Age? • (if young, often strabismus, if older, often cranial nerve palsy) • Monocular vs Binocular • Horizontal vs Vertical vs Oblique vsTorsional • Intermittent vs Constant • Worse in a certain direction of gaze? • Time Frame • Rule out GCA, aneurysm (CN III palsy) • Vascular risk factors (DM, HTN, dyslipidemia) • Think if Ophthalmologic or Neurologic

  34. Consulting Ophthalmology • Call anytime you are worried! • 24hr coverage for inpts and outpts (RAH) • 735-4111 • Take a history and check vision first  • Call anytime day/night (including, but not limited to) • Acute loss of vision (eg. CRAO, AAION – think GCA!) • Angle closure glaucoma • Ruptured globe • Retrobulbar hemorrhage • Orbital cellulitis • Corneal Ulcer • Endophthalmitis • If you are comfortable, pts who don’t need to be seen by ophthalmology: • Viral conjunctivitis • Corneal abraison • Subconjunctivalhemorrage • Dry eyes

  35. Summary • Pt with an eye problem? Don’t panic • History – HPI, past ocular/surgical hx, trauma? • Eye exam – VA, pupils, external exam • Classification systems • Acute loss of vision, Chronic loss of vision • Red eye (traumatic, non-traumatic) • Diplopia, Pupillary abnormalities • Remember the common and the worrisome problems – most patients will fit into one of these • Call for Help if you’re unsure

  36. Eye Handbook

  37. Pupillary abnormalities Are pupils equal? No Yes Anisocoria Isocoria Physiological“simple” anisocoria( 0.5mm) Pathological Bilateral impairmentof pupil light reflexes Afferent pupil defect(uni-or bilateral) See vision disorders Local iris dysfunction Impaired dilatation:sympathetic dysfunction(Horner’s syndrome) Small pupils(Argyll Robertson pupils) Large pupils Angle-closure glaucomaIritis / synechiaeTrauma Syphilis Diabetes mellitus NMJ dysfunction Botulism Pharmacological Impaired constriction:parasympathetic dysfunction Preganglionic Postganglionic Cluster headacheTraumaticIdiopathicCarotid dissection IdiopathicTraumaticTumour (lung, breast, thyroid) Dorsal midbrainsyndrome Tumor Hemorrhage Hydrocephalus Preganglionic:Oculomotor nerve / fascicle NMJ dysfunction PharmacologicalFactitious Usually with other CN III findings Postganglionic:Tonic (Adies’s) pupil

  38. Chronic vision loss 1-Distorted vision? Blind spots (scotomas)? 2-Drusen Atrophy 1-Decreased central vision? Multiple images at night? Glare? 2-Decreased red reflex? Poor visibility of fundus? 1-Subacute vision loss? Unilateral blur Headache Imaging + visual field testing 1-Bitemporal hemianopia? Blur? Asymptomatic? Headache? Field testing 1-History of DM? Blur? 2-Cotton wool spots? Neovascularization? 1-Peripheral vision loss? Blur? Asymptomatic 2-Increased IOP (N=10-20 but normal doesn’t exclude it) Disk cupping 1-Discomfort? Blur? 2-Cornea not clear? Cataract Pituitary lesion (adults)Meningioma (adults)Craniopharyngioma Maculardegeneration Optic nervecompression DiabeticRetinopathy Chronic openangle glaucoma Cornealopacification 1-Symptoms 2-Signs

  39. References • 1. http://en.wikipedia.org/wiki/File:Snellen_chart.svg • 2. iTunes - Eye Handbook app • 3. AAO Neuro-ophthalmology Manuel • 4. http://www.vision-and-eye-health.com/vision-screening.html • 5. http://www.studyblue.com/notes/note/n/pe-slide-exam/deck/6277983 • 6. http://www.iefusa.org/Catalog/SRS_FRONT/ProdDetail.php?s_category_id=21&product_id=1004

  40. References • 7. http://www.med.uottawa.ca • 8. http://www.aapos.org/terms/conditions/39 • 9. www.aao.org/theeyeshaveit/trauma/hyphema.cfm • 10. http://www.tedmontgomery.com/the_eye/eyephotos/RetinalDetachment-1.html • 11. http://www.tumblr.com/tagged/retinal%20detachment • 12. http://www.eyecenters.com/what-you-should-know-about-retinal-detachment.html • 13. http://www.aao.org/theeyeshaveit/non-trauma/artery-occlusion.cfm • 14. www.snec.com.sg

  41. 15.http://www.scielo.br/scielo.php?pid=S0004-27492008000200025&script=sci_arttext15.http://www.scielo.br/scielo.php?pid=S0004-27492008000200025&script=sci_arttext • 16. www.sightnation.com • 17. theeyeshaveit/trauma/hyphema.cfm • 18. www.varga.org • 19. www.midmeds.co.uk • 20. http://www.varga.org/Physician%20Assistant%20Photos.htm • 21. http://www.varga.org/Physician%20Assistant%20Photos.htm

  42. References • 22. http://www.accessmedicine.ca/search/searchAMResultImg.aspx?rootterm=globe+rupture&rootID=44128&searchType=1 • 23. www.medicationathome.com • 24. http://www.emedicinehealth.com/subconjunctival_hemorrhage_bleeding_in_eye/page12_em.htm • 25. sinusitisunderstood.blogspot.com • 26. http://emedicine.medscape.com/article/1217858-overview

  43. References • 27. http://www.sarawakeyecare.com/Atlasofophthalmology/anteriorsegment/Anteriorsegment44fungalcornealulcer.htm • 28. www.ejournalofophthalmology.com

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