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 sightthreatening disorders and those that can be managed safely by the primary care physician ID: 598306
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Slide1
Essentials of OphthalmologySlide2
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 diseaseSlide3
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, Slide4
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)Slide5
The basic eye exam
*
*Slide6
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 Slide7
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)Slide8
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)Slide9
Visual acuity
The pinhole (PH) exam can show refractive error
Need a pinhole occluder
Central rays of light do not need to be refractedSlide10
Sensory visual function
Stereopsis (perception of depth), contrast sensitivity, glare, color vision
The red desaturation testSlide11
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)Slide12
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)Slide13
Pupillary
exam: RAPD
sft.jpgSlide14
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)Slide15
corneal light reflex
Normal or straight
Exotropia
EsotropiaSlide16
corneal light reflex
Be aware of pseudoesotrpoia in children with epicanthal foldsSlide17
cover testing
Cover-uncover or alternating cover testing can reveal strabismus as non-occluded eye fixates on object Slide18
Ocular alignment & motility
Elevation, depression, abduction, adduction
0
0
0
0
-3
-1
-1
-3Slide19
Confrontational visual fieldsSlide20
Intraocular pressure
Measured by tonopen or palpation
Varies throughout the day, normal is 10-22
Palpation may be useful if you suspect angle closure glaucomaSlide21
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?Slide22
BlepharitisSlide23
Case 1Slide24
Chalazion
Treatment
warm compresses
lid hygiene
surgical incision and curettage
steroid injection
pathological examination for suspicious lesionSlide25
ChalazionSlide26
Acrochordon
Shave excision
Gentle
cautery
to baseSlide27
Cutaneous Horn
Exuberant hyperkeratosis
Biopsy of baseSlide28
Seborrheic Keratosis
Waxy, stuck-on
Shave at dermal-epidermal junction
Rapid
reepithelizationSlide29
Case 2Slide30
Basal Cell Carcinoma
Management
Biopsy
Surgical Excision
Incisional biopsy
MOHS surgery
Radiation - palliativeSlide31
Squamous
Cell CarcinomaSlide32
Squamous Cell CASlide33
Pre- Septal CellulitisSlide34
Cellulitis
:
PreSeptal
Children: most common
Associated lid swelling (upper and lower)
History of URI or sinus infection
Both may have temp and elevated WBCSlide35
Preseptal
Eye Exam normal
Patient does not appear “toxic”
Can treat with oral antibiotics and close observation
Unless in NEONATE!! hospitalizeSlide36
Orbital
A dangerous infection requiring prompt treatment
Orbital Signs:
Decreased vision
Proptosis
Abnormal pupillary response and motility
Disc swellingSlide37
Orbital
Cellulitis
CT or MRI: Look for Sinus infection or orbital abscess
Blood cultures
Conjunctival
swabs of no diagnostic value
ENT consultSlide38
Orbital
Cellulitis
Treatment
Prompt drainage of orbital or sinus abscess
Systemic IV antibiotics
Haemophilus, Staph and Strep
CephalosporinSlide39
PtosisSlide40
DermatochalasisSlide41
Case 3Slide42
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. Slide43Slide44
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.Slide45
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.Slide46
DacryocystitisSlide47Slide48
Nasal-
lacrimal
duct Obstruction
Epiphora (Tearing)
Recurrent bacterial conjunctivitis
Often history of facial trauma
Treatment: DCRSlide49
EctropionSlide50
Entropion