眼科常用檢查 主治醫師教學 98-08-25 VS 譚超毅

Ocular Emergency Examinations. Differential Diagnosis of “Red Eye” Painless visual loss. Trauma. Ocular foreign body.

Taking History Previous vision in the affected eye. Previous ocular trauma. Present medication. Details of present injury Blunt or penetrating Projectile Chemical property

Tools for Ocular Examination Snellen/Landolt C chart, near card Trial frame, occluder, pinhole Schiotz tonometry Slit lamp Ophthalmoscope

Topical Anesthetics

Topical Anesthetics Abuse

Fluorescein Stain

Cycloplegics for Examination

Visual Acuity “Vital sign” of the eye. One of the most significant prognostic indicators of eventual visual outcome. Methods Snellen chart Landolt C chart Near card

Visual Acuity Check Landolt C

Near Card

Visual Acuity Evaluations Bare vision Corrected vision Spectacles Pinhole Trial lens Description 20/20; 6/6; 1.0 Number of digit (ND), Counting finger (CF) Hand motion (HM) Light projection Light perception (LP), Light sense (LS)

Visual Acuity Evaluations Examples VA (OD): 1.0 (with pinhole (PH): 0.9) VA (OS): 0.1 (1.0x-3D=cyl-1.0D Axis 0) VA with PG: (OD) 0.8 (OS) 0.7 ND 30 cm HM 60 cm LS (+) LS (-) under slit lamp/indirect ophthalmoscope light

Measurement of Intraocular Pressure Normal range of intraocular pressure: 6-21 mmHg Indentation tonometry increased pressure or firmer eyes are less readily indented with Schiotz plunger low Schiotz reading  high pressure Applanation tonometry In increased pressure or firmer eyes, more pressure are required to flatten a small area of the cornea high reading  high pressure

Measurement of Intraocular Pressure: Schiotz The 5.5 weight is preset, make sure that the plunger moves freely The Schiotz can be autoclaved if necessary, but usually the base is wiped clean with an alcohol wipe. Zero the instrument by placing it on the steel plate within the box, and ensure that the arm reads "0"

Measurement of Intraocular Pressure: Schiotz Place topical anesthesia on the cornea and lie the patient flat. Gently lower the plunger onto cornea and keep the instrument steady by holding the handles; do not push the instrument into the cornea. Take the reading off the scale and convert to mm Hg by table. If the reading is at the low end of the scale (high pressure) add a second weight (7.5g or 10g) to the plunger and retake

Measurement of Intraocular Pressure Applanation Tono-Pen Air-puff

Pupillary Examination Size of pupils Configuration of pupils Swinging light test Relative afferent pupillary defect (RAPD) Marcus Gunn pupil

Light Reflex Pathway

Swinging Light Test: normal

Swinging Light Test: abnormal

Pupillary Examination Limitations Bilateral abnormalities of optic nerve Marked opacities of the optic media Corneal opacity Dense cataract Vitreous hemorrhage Diffuse retinal abnormality Monocular patient

Extraocular Muscle Motility Orbital floor fracture May impair vertical gaze in affected eye Nerve Palsies Trauma is the most common cause of cranial nerve palsies under the age of 45 CN 3 palsy With minor head trauma is unlikely – if present may indicate previously occult pathology CN 4 palsy Often bilateral when secondary to trauma

Extraocular Muscle Motility

External Ocular Examination Review sensory and motor innervations of lids Inspect for ptosis, proptosis, entropion, ectropion, common lid lesions (chalazion, papilloma,basal cell ca.) Review the location of the lacrimal gland, puncta, canaliculi, nasolacrimal sac and duct

External Ocular Examination Have the patient follow a target with the eyes to the extremes of gaze Limbus should be in the same position in both eyes for upward & downward gaze Gently lift the upper lids in downgaze to check the position of the cornea

Slit Lamp

Slit Lamp Examination

Anterior Segment Examination Examine from front to back anatomically: lids, lacrimal, lashes, sclera, conjunctiva, cornea, iris, anterior chamber, lens Lids, lashes and adnexal structures first to identify blepharitis etc. Scleral examination can ask patient to look left/right/up/down in order to view the entire sclera

Anterior Segment Examination Conjunctiva ask patient to look left/right/up/down in order to view the entire conjunctiva Cornea for keratitis, opacities or foreign bodies Anterior Chamber depth screening Lens assessment for cataract Testing for uveitis cells or flare Use of fluorescein and cobalt blue filter

Direct Ophthalmoscope

Normal Fundus

Fundoscopy Have the examining room dark Give the patient a specific object on the wall on which to fixate Turn the ophthalmoscope on to a low-moderate light intensity Use the smallest aperture to look into an undilated eye, and the largest aperture to observe a dilated eye. Use your right eye and right hand to look into the patient's right eye (and your left eye/left hand for the patient's left eye) Look through the ophthalmoscope into the patient's eye from a distance and find the red reflex

Fundoscopy Follow the red reflex into the eye at a small angle towards the patient's nose Focus on the optic disc Follow the Superonasal arcade Follow the Inferonasal arcade Follow the Superotemporal arcade Follow the Inferotemporal arcade Focus on the macula (temporal to the optic disc)

Optic Atrophy

Major pathologies on Fundoscopy Hypertensive changes: Arteriolar spasm Exudates flame-shaped hemorrhages absence of venous pulsations, ghost vessels Atherosclerosis Glaucoma Diabetes Occlusive Pathologies

Visual Field Testing Confrontation test Amsler grid Tangen screen Kinetic visual field testing Goldmann Static visual field testing Humphrey, Octopus

Confrontation Test Confrontation is better for identifying neurological defects. Examiner uses himself as a reference point Check for fixation Both patient and examiner should be using one eye at a time. Finger counting  suppression or decreased sensitivity Red target test  subtle neurological defects

Confrontation Test

Kinetic Perimetry Neurological VF loss if post-chiasmic, will be homonymous The Goldman is a manual field machine

Automated Static Perimetry Automated is necessary for glaucoma diagnosis and management Glaucomatous VF loss follows a nerve fiber layer bundle pattern

Automated Perimetry

Normal Visual Field

Glaucomatous Visual Field Defect

Tunnel Vision