1. 眼科常用檢查
主治醫師教學
VS 譚超毅

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

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

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

5. Topical Anesthetics

6. Topical Anesthetics Abuse

7. Fluorescein Stain

8. Cycloplegics for Examination

9. 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

10. Visual Acuity Check
Landolt C

11. Near Card

12. 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)

13. 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

14. 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

15. 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"

16. 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

17. Measurement of Intraocular Pressure
Applanation
Tono-Pen
Air-puff

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

19. Light Reflex Pathway

20. Swinging Light Test: normal

21. Swinging Light Test: abnormal

22. 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

23. 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

24. Extraocular Muscle Motility

25. 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

26. 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

27. Slit Lamp

28. Slit Lamp Examination

29. 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

30. 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

35. Direct Ophthalmoscope

36. Normal Fundus

37. 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

38. 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)

39. Optic Atrophy

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

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

42. 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

43. Confrontation Test

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

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

46. Automated Perimetry

47. Normal Visual Field

48. Glaucomatous Visual Field Defect

49. Tunnel Vision