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Getting ‘Worked Up’ Ophthalmology Technical Essentials

Getting ‘Worked Up’ Ophthalmology Technical Essentials. Britta Hansen, OD, FAAO March 22, 2014. Who am I?. Berkeley Optometry Grew up in Minnesota Residency at San Francisco VA Work at Northwest Eye Surgeons. “Triage”. Outline. Components of technical exam History/chief concern(s)

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Getting ‘Worked Up’ Ophthalmology Technical Essentials

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  1. Getting ‘Worked Up’Ophthalmology Technical Essentials Britta Hansen, OD, FAAO March 22, 2014

  2. Who am I? • Berkeley Optometry • Grew up in Minnesota • Residency at San Francisco VA • Work at Northwest Eye Surgeons

  3. “Triage”

  4. Outline • Components of technical exam • History/chief concern(s) • Phone/walk-in triage • Vision, refraction • Confrontation visual fields • Extraocular motility • Pupillary reaction • Intraocular pressure, angles • Additional testing • Patient examples

  5. Chief concern/Phone Triage • Base questions upon: • What you expect as an answer • What diagnoses you’re considering/past experience • What they’ve already told you VS.

  6. Where to start? • Let the patient [briefly] tell you what’s wrong • Ask new questions that make sense: • Pain = what scale? • Redness, blurry = how long? What scale? • Headache = tried to alleviate? • Any eye drops = side effects? • Any new medications = side effects? • Injury = flashing lights, floaters, bruising?

  7. There is an art to this… • Some patients will overstate their symptoms • Others will downplay their symptoms • Knowing the right questions, trusting your instincts and continuously re-visiting your process for triage regularly

  8. How to schedule?

  9. Subjective versus Objective testing Subjective Objective Fields Motility Pupils IOP • History/Chief Concern • Vision? • Refraction?

  10. History • Patient medical history • Family medical history • Patient ocular history • Family ocular history • Which diseases are inherited? • Macular degeneration • Glaucoma • Retinal detachment • Strabismus (eye turns) • Low vision disorders: ie Retinitis pigmentosa, ocular albinism

  11. What questions help? • Location • Severity • Quality • Duration • Timing • Context • Modifying factors HPI = History of Present Illness

  12. Know Your Patient Base • Primary eye care setting • More weight on refraction, contact lens fittings • Less weight (but still important) on chair skills • Tertiary care setting • More weight on chair skills to help with diagnosis • There is overlap between the settings, knowing what to do in each instance will help to have a smooth work-up

  13. Outline • Components of technical exam • History/chief concern(s) • Vision, refraction • Confrontation visual fields • Extraocular motility • Pupillary reaction • Intraocular pressure, angles • Triaging patient examples “Chair Skills”

  14. The Eyes are an extensionof the Brain!

  15. Visual fields • Finger Counting: all or none • Transilluminatorfields: all or none • Automated perimetry: qualify visual field defect • Humphrey • Matrix • FDT • Abnormal fields: • Glaucoma, other optic nerve problems • Retinal detachments • Vein and artery occlusions • Stroke, tumor

  16. Extraocular motility • Tropia: one eye turns in (eso) or out (exo) • Main question: do you see double?

  17. Extraocular Muscles • “Double Vision:” poor blood flow to muscles around the eye, muscle trapped from free movement

  18. Extraocular Muscles • Patients with SYMPTOMATIC double vision will tell you. PUPILS can be very important in this case.

  19. Extraocular movements

  20. Reasons for rare eye movements • Poorly controlled diabetes • Poorly controlled blood pressure • Graves Disease • Congenital • Entrapment from an injury • Anomalies of the nerves • Compression to the nerves or the muscles

  21. Pupillary Action

  22. What to look for • Equal size/shape • Equal reaction to light • Similar movement when the light is in the other eye • Relatively the same movement when swinging back and forth

  23. Pupillary testing • Anisocoria- difference between pupil size • Horner’s- miotic (small) pupil • Adie’s- acute dilated pupil • Relative Afferent Pupillary Defect • If present, it can be VERY important as a component of the doctor’s exam • This is a RELATIVE difference between the two eyes and their brain input

  24. Things that cause an RAPD • Asymmetric glaucoma • Blood loss to the OPTIC NERVE in one eye • Retinal detachment in one eye • Blood loss to the RETINA in one eye • Compression on the optic nerve in one eye • NOT: Cataract • NOT: Amblyopia • NOT: Macular Degeneration or Scar

  25. Pupillary Demonstration • http://www.richmondeye.com/wp-content/uploads/2014/01/d097550bb4b088bb4853b2992c86d90a.htm

  26. Complicated Pupils • One pupil doesn’t work because of an iris injury • A patient has a new concern in the “good eye” where the “bad eye” already has a relative pupil problem

  27. Vision • Monocular? Binocular? • Without correction? With Correction? • Distance? Intermediate? Near? • Pinhole?

  28. Vision • Reduced vision • Glasses wrong/outdated • Cataract • Macular disease (edema, epiretinal membrane, macular degeneration) • Sudden loss of vision (vascular disorder, retinal detachment)

  29. Refraction • Change from glasses? • Best “corrected” visual acuity

  30. Range of Concerns and Diagnoses • Glasses change: gradual • Can be due to Diabetic shift in blood sugar • Cataract: blurry vision through glasses, glare while driving at night, haloes and starbursts • Retinal detachment: flashing lights, shower of new floaters, dark curtain over vision, blurred vision • Open angle glaucoma: no symptoms until late in the disease, high pressure in this case is painless

  31. Range of Concerns and Diagnoses • Vitreous detachment: floaters in presence or absence of flashing lights, no vision loss, usually distinct floater(s) • Acute Angle Closure Glaucoma: Recent pupillary dilation, foggy vision

  32. Posterior Vitreous Detachment http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/weiss-ring.html

  33. Concerns and Diagnoses: PINK EYE • Bacterial conjunctivitis: pus-like discharge, eyes stuck shut in morning, usually children • Viral conjunctivitis: white/clear discharge, contact with someone else with a red eye, current or recent past upper respiratory infection, swollen, one or both eyes • Uveitis: sensitivity to light, redness • Scleritis: extreme eye pain, extreme redness

  34. Concerns and Diagnoses • Allergic conjunctivitis: watering and itching of eyes, usually seasonal, current runny nose/cough/sneezing

  35. Concerns and Diagnoses: DOUBLE VISION • Nerve palsy: symptoms only when both eyes open, certain gazes have less double than others, may have diabetes, hypertension, Graves, or other systemic diseases • May have lid droop, pupillary problem as well

  36. Concerns and Diagnoses • Acute angle closure glaucoma: vomiting, nausea, rainbows around lights, worse in morning, can be precipitated by dilation • Transient ischemic attack: blacked out vision lasting seconds to less than 5 minutes, returns to normal, typically older patients with history of high cholesterol • ***IF symptoms coincide with unilateral weakness, trouble findings speech or trouble ambulating, send patient immediately to ER

  37. Concerns and Diagnoses • Foreign body: patient usually knows when it went in • Penetrating injury: high velocity, either patient or object, globe may be open, check immediately or send to ophthalmology if suspect • Endophthalmitis: extreme pain in the eye, usually after surgery or with other illness, send to ophthalmology

  38. Patient #1 • 65 yo female calls with blurry vision • FIRST question to ask: • How long has the vision been blurry? • Qualifiers • How blurry is it? • Does anything make it better? • Has anything changed • Accompanying concerns • Flashing lights, floaters, diabetes

  39. Patient #1 continued • Vision blurry x 1 year • Glasses help but not much • Has glare and haloes with oncoming headlights • Diagnosis? Likely cataract, check next available

  40. Patient #2 • 5 yo male • Red, painful eye • For the last 2 days • Got poked with a fake candy cane, went to urgent care, was given ointment, is sensitive to light • Likely diagnosis? Corneal abrasion, see same day if possible

  41. Patient #3 • 45 yo male • Blurry vision, both eyes • Cobweb in the right eye yesterday, left eye now very fuzzy • Since yesterday the left eye has been very bad • Hasn’t seen any Dr. since 2009 • Diagnosis: Proliferative Diabetic Retinopathy, see same day if possible

  42. Patient #4 • 65 yo female • Blurry vision, right eye, since yesterday • Proceeded by flashing lights/mild floaters • Now sees a curtain over vision • Likely diagnosis: Retinal detachment, see today

  43. Patient #5 • 20 yo female • Red, painful left eye • Very sensitive to light, vision mildly blurred • Has systemic lupus • Likely diagnosis: Unilateral uveitis, see today or tomorrow

  44. Finally!

  45. Britta Hansen, OD, FAAO bhansen@nweyes.com

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