1. Essentials of Ophthalmology

2. Learning Objectives
At the conclusion of this presentation, the participant should be able to:
Understand how to perform the basic eye exam
Understand the differences between sight-threatening disorders and those that can be managed safely by the primary care physician
Diagnose common ophthalmic disease

3. The basic eye exam The tools: visual acuity chart near card
bright light
direct ophthalmoscope
tonopen
slit lamp
eye drops: topical anesthetic, dilating drops
fluorescein dye,

4. The basic eye exam History & physical
History: glasses, contacts, surgery, trauma,
Symptoms: foreign body sensation (surface problem), itch (allergy), photophobia (uveitis), diplopia (orbital or CN problem), flashes or floaters (retina problem), color vision or distortion (retina problem)

5. The basic eye exam * *

6. The basic eye exam Visual acuity Pupils Alignment & Motility
Visual fields (VF)
Intraocular pressure
External exam: lids, conjunctiva, sclera, cornea,
Fundoscopy: optic nerve, vessels, macula, periphery

7. Visual acuity
Typically measured by Snellen acuity but there are many optotypes (letters, tumbling E, pictures)
May be tested at any distance
Recorded as fraction (numerator is testing distance, denominator is distance at which person with normal vision would see figure)

8. Visual acuity Measured without & without glasses (BCVA & UCVA).
Occlude one eye, children need to be patched
20/20 to 20/400, CF (counting fingers), HM (hand motion), LP (light perception), NLP (no light perception)

9. Visual acuity The pinhole (PH) exam can show refractive error
Need a pinhole occluder
Central rays of light do not need to be refracted

10. Sensory visual function
Stereopsis (perception of depth), contrast sensitivity, glare, color vision
The red desaturation test

11. Pupillary exam Pupil size - measure with pupil gauge on near card
Anisocoria should be recorded under bright and dim light (greater than 1 mm is abnormal)

12. Pupillary exam
Relative afferent pupillary defect (RAPD) or Marcus Gunn pupil (has nothing to do with size of pupils but the comparitive reaction to light)
Detected with swinging flash light test
Indicates unilateral or asymmetric damage to anterior visual pathways (optic nerve or extensive retinal damage)

13. Pupillary exam: RAPD
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14. Ocular alignment & motility
Strabismus is misalignment of the eyes
Important to recognize in children to prevent development of amblyopia
Phoria is latent tendency toward misalignment
Tropia is manifest deviation (present all the time)

15. corneal light reflex
Normal or straight
Exotropia
Esotropia

16. corneal light reflex
Be aware of pseudoesotrpoia in children with epicanthal folds

17. cover testing
Cover-uncover or alternating cover testing can reveal strabismus as non-occluded eye fixates on object

18. Ocular alignment & motility
Elevation, depression, abduction, adduction -3 -3 -1 -1

19. Confrontational visual fields

20. Intraocular pressure Measured by tonopen or palpation
Varies throughout the day, normal is 10-22
Palpation may be useful if you suspect angle closure glaucoma

21. External exam
Lids & lashes (head, face, orbit, eyelids, lacrimal system, globe)
Compare symmetry, use your ruler
Flip the lid; make a lid speculum
What am I seeing?

22. Blepharitis

23. Case 1

24. Chalazion warm compresses lid hygiene surgical incision and curettage
Treatment
warm compresses
lid hygiene
surgical incision and curettage
steroid injection
pathological examination for suspicious lesion

25. Chalazion

26. Acrochordon
Shave excision
Gentle cautery to base

27. Cutaneous Horn
Exuberant hyperkeratosis
Biopsy of base

28. Seborrheic Keratosis Waxy, stuck-on
Shave at dermal- epidermal junction
Rapid reepithelization

29. Case 2

30. Basal Cell Carcinoma Management Biopsy Surgical Excision
Incisional biopsy
MOHS surgery
Radiation - palliative

31. Squamous Cell Carcinoma

32. Squamous Cell CA

33. Pre- Septal Cellulitis

34. Cellulitis: PreSeptal
Children: most common
Associated lid swelling (upper and lower)
History of URI or sinus infection
Both may have temp and elevated WBC

35. Preseptal Eye Exam normal Patient does not appear “toxic”
Can treat with oral antibiotics and close observation
Unless in NEONATE!! hospitalize

36. Orbital A dangerous infection requiring prompt treatment
Orbital Signs:
Decreased vision
Proptosis
Abnormal pupillary response and motility
Disc swelling

37. Orbital Cellulitis
CT or MRI: Look for Sinus infection or orbital abscess
Blood cultures
Conjunctival swabs of no diagnostic value
ENT consult

38. Orbital Cellulitis Treatment
Prompt drainage of orbital or sinus abscess
Systemic IV antibiotics
Haemophilus, Staph and Strep
Cephalosporin

39. Ptosis

40. Dermatochalasis

41. Case 3

42. Inflammations Thyroid Eye Disease
Thickening of the EOM, orbital fat herniation, proptosis, retraction of both the upper and lower eyelids, descent of the eyelid-cheek complex, and divergence of gaze occur.
eyelid edema, conjunctivitis, photophobia, chemosis, lagophthalmos, headache, gritty sensation in the eye, retrobulbar pain, and tearing.

44. Clinical Manifestion
Optic neuropathy occurs in less than 5% of Graves orbitopathy, but it is the most common cause of vision loss in this setting; the progression is usually insidious. This neuropathy usually occurs in patients with proptosis, but can occur in patients without significant proptosis.
Except for cases of rapidly progressive exophthalmos the eyelids are capable of closing sufficiently to protect the cornea. Thus, while approximately 50% of Graves patients experience eye symptoms, only approximately 5% of cases are severe enough to warrant intervention.
Diagnosis (2 of 3)
TBII = thyroid binding inhibitory immunoglobulins
6% are Euthyroid
Eyelid retraction most common ophthalmic feature at 90%, proptosis 60%, strab 40%
<2% develop optic neuropathy

45. Thyroid Eye Disease
A complete ophthalmologic exam is necessary. The amount of globe protrusion is measured using Hertel exophthalmometry.
Assessment of V.A, V.F, and color saturation must be performed to exclude optic neuropathy.
Nasal endoscopy for diagnosis any sinonasal problems such as septal deviation or polyposis. In addition, the thyroid gland should be palpated.

46. Dacryocystitis

48. Nasal-lacrimal duct Obstruction
Epiphora (Tearing)
Recurrent bacterial conjunctivitis
Often history of facial trauma
Treatment: DCR

49. Ectropion

50. Entropion