Ophthalmologic Evaluation

History Demographic data Chief complaint History of present illness Past ocular history Past systemic history Family history

Demographic Data Name Address Date of birth Gender Race Medical record number

Chief complaint Should be recorded in the patient’s own words or in a nontechnical paraphrasing of the patient’s words

History of Present Illness Time and manner of onset. Was it sudden or gradual? Severity. Has the problem improved, worsened, or remained the same? Influences. What might have precipitated the condition, made it better or worse, or made no difference? Constancy and temporal variations. Has the problem been intermittent or seasonal, or does it worsen at a particular time of day? If so, were there any influences that seemed to precipitate exacerbations or remissions? Laterality. Is the problem unilateral or bilateral? Clarification. Clarify what the patient means by certain complaints. Documentation. Old records or old photographs can be of value in documenting the presence or absence of particular problems in the past.

Past Ocular History Use of eyeglasses or contact lenses Use of ocular medications in the past Ocular surgery (including laser surgery) Ocular trauma History of amblyopia (lazy eye) or of ocular patching in childhood

Ocular Medications Current and prior ocular medications used for the present illness – Dosages – Duration – Frequency Over-the-counter medications Home remedies Herbal medicines Dietary supplements

Past Systemic History Diabetes mellitus HTN Malignancy Dermatologic Cardiac Renal Hepatic Pulmonary GI Autoimmune collagen vascular diseases (including arthritic) Surgeries

Allergies Allergic reactions to topical or systemic medications Allergies to environmental agents resulting in: – Atopic dermatitis – Asthma – Allergic rhinitis, conjunctivitis – Urticaria – Vernal conjunctivitis

Family History Ocular diseases Familial Systemic Diseases – Atopy – Thyroid disease – HTN – Diabetes mellitus – Malignancies

Examination Visual acuity examination Examination of the external eye and ocular adnexa Pupillary examination Posterior segment examination

Visual Acuity Notations and Abbreviations AbbreviationStands for VAVisual acuity ccWith correction scWithout correction PHPinhole ODRight eye OSLeft eye OUBoth eyes JJaeger notation

Visual Acuity Notations and Abbreviations AbbreviationStands for CFCounting fingers HMHand motion LP c projLight perception with projection LP s projLight perception without projection NLPNo light perception CCentral SSteady MMaintained F/FFixes/follows 20/40 -2 Missed 2 letters on 20/40 line 20/50 +2 Read 2 letters on the line following the 20/50 line

Testing Distance Visual Acuity 1.Ask the patient to stand or sit 20 feet from the Snellen chart. 2.Occlude the left eye. 3.Ask the patient to read down the chart as far as possible. 4.Note the corresponding acuity measurement at that line of the chart. Record the visual acuity for each eye separately, with correction and without correction. If the patient misses half or fewer than half the letters on the smallest readable line, record how many letters were missed; for example 20/ If acuity is worse than 20/20, recheck with a pinhole. 5.Repeat steps 1-4 for the left eye, with the right eye covered.

Low Vision Testing If a patient is unable to read the largest line of the visual acuity testing chart at 20 ft, move the patient 5 ft closer to the chart (15 ft, 10 ft, 5 ft). – Ex.: 5/200 (Patient can read the 20/200 line successfully while standing 5 ft in front of the chart) If the patient is unable to read the largest line at 5 ft, proceed to measure ‘counting fingers’ vision. Ask how many fingers are held up, and if an accurate response, record as CF and the distance measured (4 ft, 3 ft, 2 ft, 1 ft). If CF cannot be seen, move your hand in front of the patient’s eye and if movement is accurately seen, record a VA of HM. If hand movements are not perceived, shine a penlight into the eye from various angles and record whether or not the patient has light perception (LP), and from which direction it is perceived. If still no light perception, record the vision in that eye as NLP.

Testing Visual Acuity in Preschoolers Tumbling E chart – In this test, the only figure presented is an upper case E. – The E is presented in any one of four positions: normal, backwards, upside down on its "back" and turned with its back up. – The child is asked to show which direction the E is pointing by pointing with the hand.

Tumbling E chart

Testing Visual Acuity in Infants Fixes and follows (F & F) or Central, steady, maintained (CSM)

Testing Visual Acuity in Infants If the baby can hold fixation on a target and follow it around in space as the target moves, this visual acuity is noted as "fix and follow". Make sure to check for fixation behavior with each eye, as well as binocularly.

Testing Visual Acuity in Infants If each eye fixates centrally rather than eccentrically, holds steady fixation on that target rather than searching for it or wandering, and continues to stay fixated on that target even when occlusion is removed from the fellow eye, the vision is noted "CSM". Make sure to check for fixation behavior with each eye, as well as binocularly.

Testing Visual Acuity in Infants If there is a fixation preference, then typically the preferred eye has CSM for the visual acuity and CSNM (central, steady, not maintained) for the fellow eye. If there is nystagmus present, then the fixation would likely be CNSM (central, not steady, maintained) if the patient was fixating centrally despite the nystagmus.

Testing Near Visual Acuity 1.Instruct the patient to hold the test card at a distance specified on the card (14 inches). 2.Ask the patient to occlude the left eye. 3.Ask the patient to read the smallest print that they can comfortably see. 4.Record the acuity value for each eye separately, with and without correction. 5.Repeat the procedure with the right eye occluded and the left eye viewing the chart.

Jaeger eye chart

Rosenbaum pocket vision screener

Amsler grid If you wear reading glasses, put them on for this test. Hold the chart at a comfortable reading distance. Cover one of your eyes. Look at the grid. Keep your eye focused on the white dot at the center of the grid throughout the test. Without moving your eye from the center dot, notice the lines which make up the grid. All of the lines should be straight, and all of the squares should look the same. There shouldn’t be any blank, dark, or distorted areas on the grid. Use the same procedure to test your other eye.

Amsler grid

Eyelids Edema Redness Direction of the eyelashes

Eyelashes Matted eyelashes

Conjunctiva Hyperemia

Sclera Icteric

Cornea Opacities

Iris Color (brown in Asians)

Anterior Chamber With your light shining directly from the temporal side, look for a crescentic shadow on the medial side of the iris. Since the iris is normally fairly flat and forms a relatively open angle with the cornea, this lighting casts no shadow.

Pupils Size, shape, symmetry Pupillary reactions to light – The direct reaction (pupillary constriction in the same eye) – The consensual reaction (pupillary constriction in the opposite eye)

Extraocular Movements Ask the patient to follow your finger or pencil as you sweep through the six cardinal directions of gaze. Making a wide H in the air, lead the patient’s gaze to the patient’s extreme right (2) to the right and upward (3) down on the right (4) without pausing in the middle, to the extreme left (5) to the left and upward (6) down on the left

Ophthalmoscope

Steps for Using the Ophthalmoscope Darken the room. Switch on the ophthalmoscope light and turn the lens disc until you see the large round beam of white light. Turn the lens disc to the 0 diopter (a diopter is a unit that measures the power of a lens to converge or diverge light). Remember, hold the ophthalmoscope in your right hand to examine the patient’s right eye; hold it in your left hand to examine the patient’s left eye.

Steps for Using the Ophthalmoscope Hold the ophthalmoscope firmly braced against the medial aspect of your bony orbit, with the handle tilted laterally at about a 20° slant from the vertical. Check to make sure you can see clearly through the aperture. Instruct the patient to look slightly up and over your shoulder at a point directly ahead on the wall. Place yourself about 15 inches away from the patient and at an angle 15° lateral to the patient’s line of vision. Shine the light beam on the pupil and look for the orange glow in the pupil—the red reflex. Note any opacities interrupting the red reflex.

Steps for Using the Ophthalmoscope Now, place the thumb of your other hand across the patient’s eyebrow (this technique helps keep you steady but is not essential). Keeping the light beam focused on the red reflex, move in with the ophthalmoscope on the 15° angle toward the pupil until you are very close to it, almost touching the patient’s eyelashes.

Steps for Examining the Optic Disc and Retina First, locate the optic disc. Look for the round yellowish orange structure. If you do not see it at first, follow a blood vessel centrally until you do. Now, bring the optic disc into sharp focus by adjusting the lens of your ophthalmoscope. – If both you and the patient have no refractive errors, the retina should be in focus at 0 diopters.

Posterior Pole

Optic Disc The sharpness or clarity of the disc outline The color of the disc – yellowish orange to creamy pink The size of the central physiologic cup, if present. It is usually yellowish white. – Nomral cup-disc (CD) ratio:

Cup-to-disc ratio The ratio of the horizontal diameter of the physiological cup to that of the horizontal diameter of the optic disc. It should be less than 0.5. If it exceeds that value, or if there is a difference in ratio between the two eyes, or if there is a progressive enlargement of the cup, glaucoma may be suspected

Cup-to-disc ratio

Normal optic nerve with small cup Cup-to-disc ratio is 0.2

Moderately advanced cupping Cup-to disc ratio is 0.7

Almost total cup with cup-to-disc ratio of 0.9

Retinal Blood Vessels

A/V Ratio The A/V ratio is the ratio of the arteries width to the veins and a normal finding would be 2/3.

A/V ratio 2:3

A/V ratio 1:3