PD Tranx- Eye

8/6/2019 PD Tranx- Eye

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Clinical History 1 General Data Age some diseases are more

commonto certainagegroups

20 yr old patient with blurring ofvision probably dueto anerror

ofrefraction

40 yr old patient with blurring ofvision probably dueto

presbyopia

70 yr old patient with blurring ofvision probably dueto a cataract

Sex Nationality some diseases are found

more commonly in certainraces

Openangleglaucoma commonin blacks

Myopia common inthe yellowrace

Number ofadmissions Dateand time ofadmission

1 ChiefComplaint symptom ofeye diseasebotheringthe patient;reason why patient

sought consultation

Use informants own words mostaccurate description ofthe symptom

1 History of Present Illness characterizethesymptoms

Onset of signs and symptoms Preceding circumstances to the onset

ofSSx

Duration ofSSx

Character ofSSx Aggravating Factors Relieving Factors Medications used (ifany)

1 PastMedicalHistory Hypertension Diabetes mellitus Trauma Surgery

Other previous illness related to theeye

ex.Glaucoma when you have it,you have itall yourlife

1 Family History Diabetes mellitus Hypertension Other ocular diseases

*patient should betold to inform other

family members if s/hehas a familial disease

(e.g.glaucoma)

Symptoms o Eye Disease

1. Disturbance of Visiona. Decreased visualacuity malabo ang paningin,as in cases of cataracts and macular degeneration

A.Normal B. Early cataract

Subject: Physical DiagnosisTopic: History Taking and Ophthalmologic

ExaminationLecturer: Dr. Silvestre A. Pascual Jr.Date of Lecture:Transcriptionist: PolkadotsPages:

SY

2011-2012


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C.Macularhole/degeneration D. Late cataract

b. Abnormal color visione.g. Protanopia brightness ofred and orangeare muchreduced

c. Abnormal visual fields ifaffecting only oneeye, most probably = optic nerve problem oraretinalproblem,as in cases ofretinal detachment

Hemianopsia loss of vision inhalf ofthe visual field Quadrantanopsia wala dawtalagang ganitong term

A.Hemianopsia B.Quadrantinopsia*

d. Iridescent vision seeinghalos aroundlight (figure 3)

usually secondary to cornealedema,

which can be caused by increased

intraocular pressure

edematransforms the cornea into

multiple prismsbreaks thelightyou

seehalos

Iridescent vision.

e. Floaters usually black but may comein other colors

secondary to opacities inthe vitreous

humorlight strikes the opacitycasts a

shadow ontheretina

Floaters.


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f. Photopsia seeing flashes oflight may be central or secondary to other problems (e.g. migraine)

occurs whenthere is mechanical stimulation oftheretina

g. Metamorphopsia change inthe shape ofthe object seen,as in cases of obliqueastigmatism,edema ofthe maculararea,and foveal cysts

A.Obliqueastigmatism B. Edema ofthe maculararea

h. Diplopia double vision2. Pain

a. Foreign body sensation foreignobject (e.g.eyelash) onthe cornea or

conjunctiva

Foreign body sensation

b. Deep pain withintheeye could becaused by suppurative inflammation of

theeye

Pus intheeye2to a corneal ulcer = deep

pain

c. Headached. Burning, itching patient withherpes

zoster ophthalmicus may havea

burning, itching sensationaround the

eye

Herpes zoster ophthalmicus

e. Photophobia fear oflight becausepatientexperiences pain when

exposed to light

inflammation ofthe structures inthe

anterior chamber oftheeye, i.e.

anterior uveitis

Iritis inflammation ofthe iris eye is exposed to lightiris will

constrictthe pupil pain


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Photophobia

3.AbnormalSecretion from Eyes

Types of secretion

A) Lacrimation production of secretions oftheglands that cleanand lubricatetheeyes.-- active secretion oftears; increased amount oftears

B) Epiphora - is overflow oftears onto the face.A clinical conditionthat constitutes insufficienttear film

dra

inage

from

thee

ye

s in

that

tear

s will

dra

in

down

the

fa

ce

rather

than

thr

ough

the

na

sola

crim

alsys

tem

.It

can

be caused by occular irritationand inflammation oran obstructed tear outflow tract (ectropion, punctal,

canalicular ornasolacrimal duct obstructionetc.).

-- passivetearing; block inthe drainage oftears

C) Discharge

a. mucoid resembling mucus, can be caused by allergic reaction.

b. mucopurulent - is theemission or secretion of fluid containing mucus and pus, dueto

bacterial infection

ex. conjunctivitis

c. purulent - whitish-yellow exudate inflammatory pyogenic bacterial infections

ex.A mother may transmitgonorrheato hernewborn during childbirth; whenaffecting

the infant's eyes, it is referred to as ophthalmianeonatorum.

OphthlmiaNeonatorum

4. PhysicalSigns Described by Patients as Symptoms

A.REDNESS - dueto swollen or dilated blood vessels, which causethe surface oftheeyeto look red. It

appears red becausethe vessels inthe surface ofthe white portion oftheeye (sclera) becomeenlarged and

irritated. It is commonly caused by eye infections or inflammationand can occur in differentlocations.They

causeredness as wellas possible itching, discharge, pain, or vision problems.


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B.NEW GROWTH - anabnormal mass oftissueas aresult ofneoplasia,abnormal proliferation of cells.May be

benign, pre-malignant (carcinoma in situ) or malignant (cancer). It can occur inthe cornea, conjunctiva,eyelids

etc.

C.ABNORMAL POSITIONOF LIDS theeyelids are deviated from its normal position.

a. Entropion - rolling inward oftheeyelids, may causeabrasions ofthe corneaand/or irritation oftheconjunctiva.

b. Ectropion - rolling outward oftheeyelids

c. Ptosis - is a (drooping) ofthe upper orlowereyelid, sometimes called "lazy eye"

Causes: Congenital,Aging,Scarring,Mechanical,Allergic, Facialnerve palsy,Anti-cancertreatments.

D.ABNORMAL POSITIONOF THE EYES can be detected by reflection oflight on cornea. (reflection should be

from center of cornea.)

a. Esotropia - is a form of strabismus(is a condition in whichtheeyes arenot properly aligned witheach

other,typically involves alack of coordination betweentheextraocular muscles) in which one or both

eyes turns inward.

b. Exotropia - is a form of strabismus wheretheeyes are deviated outward.


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E. PAPILLARY ABNORMALITY abnormal shapes of pupil or multi-pupils.

a. Polycoria - a pathological condition oftheeye characterized by morethan one pupillary opening in

the iris. It may be congenital or may result from a diseaseaffectingthe iris.

b.Corectopia - the displacement oftheeye's pupil from its normal, central position. It may be

associated withhigh myopia orectopialentis (displacement or malposition oftheeye's crystallinelens).

F.OPACITIESAND DISCOLORATION

y Opacity is an impenetrability to visiblelight,includinglong-term exposureto ultravioletlight,exposureto radiation, secondary

effects of diseases suchas diabetes,

hypertensionand advanced age, ortrauma

(possibly muchearlier); usually results from

denaturation oflens protein.Some drugs,

suchas corticosteroids can induce cataract

development.

y Discoloration could result from a seriousdisease including cancer or somethingas

minoras fatigue oreyestrain.Also can be

caused by aharmless broken blood vessel.

Ophthalmologic Examination

1) VisualAcuity

y theevaluation should always begin with visualacuity assessmentto avoid possibleerrors which mightcome from otherassessments

y Measures central visual functiony Assesses the integrity of optical media, maculararea,and its neuralelementsy Tests are done for both distanceand near


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* Noticetherelationship of ciliary muscleand lens whichare important components ofaccommodation.

A. Distance visiontest

- inthenon-accommodated state (far sight)

- test distance of 6 meters,eacheye is tested oneatatime

- makes use ofSnellens chart- Pinhole testmay be doneto detecterrors ofrefraction (in orderto eliminate peripheralrays whateverthe

length oflocallense. Ithelps to confirm whether it is a focusing problem ornon-optical problem

Ex. dueto a possible disease process withintheeye)

B.Near visiontest

- intheaccommodated state

- test distance is 35 mm, may test botheyes at sametime

- usually done on patients >35 years (dueto stiffness oflens which is related to accommodation)

- makes use of Jaegers chart

Gross Examination

y Involves thegross inspection,and attimes (especially whenthere is presence of mass) palpation oftheexternaleyeand its adnexae

y Anatomicalrelationships, sizeand symmetry should be carefully observedy Familiarity withnormal dimensions

Inspection oftheUpper PalpebralConjunctiva:

Instruct the patient to look down. Get the patientto relax the eyes by reassurance and by gentle,

as- sured, and deliberate movements. Raise the

upper eyelid slightly so that the eyelashesprotrude, and then grasp the upper eyelashes and

pull them gently down and forward. Place a small stick such as an ap- plicator or a

tongue blade at least 1 cm above the lid margin

(and therefore at the upper border of the tarsal

plate). Push down on the stick as you raise the

edge of the lid, thus everting the eyelid or turning

it inside out. Do not press on the eyeball itself.Secure the upper lashes against the eyebrow with

your thumb and inspect the palpebral conjunctiva.After your inspection, grasp the upper eyelashesand pull them gently forward. Ask the patient to

look up. The eyelid will return to its normalposition.

Do the same steps in the lower lid.


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Takenotethe following:

y position ofglobe inrelationto lids and lid aperturey position oflids and lashesy physical signs: e.g. mass,redness, discharge, opacitiesy corneallightreflex - to det.therelative position oftheleftand therighteye inrelationto righteyey pupillary reactionto light shinealightto see constriction ofthe pupil; done on botheyes.

Extraocular Muscle MovementTwo tests: Ductionand Version

1. Ductiony tests for 6 cardinal directions ofgaze, one

eyeatatime (you can do anH intheair

with your finger)

y tests for synergistand antagonist musclefunction

y Sherringtons Law ofReciprocal Innervation:an innervational impulse flows to theactive

muscle whilethe innervational impulse is

inhibited to the muscles antagonist

2. Versiony simultaneous movement ofeyes from a

primary positionto a secondary position (6

cardinal positions)

y test for yoke muscles (muscles responsiblefor directingeyes)

y Herings Law of Equal Innervation: anequalinnervational impulse flows to each muscle

involved intheaction

Bothtests should be done,to beableto detecteven slight weakness of one muscle ofaneye.

To report findings:

Tonometry

y Measurement of intraocular pressurey It is an indirect measure oftheaqueous fluid

dynamics oftheeye.

y Used inevaluation ofglaucoma, ocularbinflammation, injuries to theeye from trauma

Methods ofMeasuring IOP

a. PalpationTonometry

y Ask the patientto look down, placetwothumbs ontheeyeball whiletherest ofthe

fingers rest onthe forehead. Press one

thumb ontheeyeball whilethe other feels

therebound.Observethe pressureand

softness/firmness.

y Reminder: do not do palpationtonometryin suspected penetrating injuries oftheeye.


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b. IndentationTonometry

y measures the pressurerequired to indentthe cornea

c.ApplanationTonometry

y measures the forcerequired to flatten orapplanateanarea of cornea.

Fundoscopy

y Direct inspection oftheretina, optic nerveand choroid

y Use ofa direct ophthalmoscopey The directexamination ofthe ocular fundus

may aid inthe diagnosis ofa primary ocular

problem orgivea clueto theearly diagnosis

ofa systemic disease.

Remember, hold the ophthalmoscope in your right hand to examine thepatients right eye; hold it in your left hand to examine the patients lefteye. This keeps you from bumping the patients nose and gives you

more mobility and closer range for visualizing the fundus.

Observe forthe following

y ROR (red-orangereflex)- thereflection oftheretina onthelens

- normal: red-orange;abnormal: white pupil (in

leukokoria)

y Media- report in findings if it is clear

y Disc Border- report in findings if it is distinct ornoty C:D Ratio

- normal: 0.3 (the cup occupies 1/3 oftheheight of

theentire disk)

y A:V Ratio- normal: 2:3 (theartery is 2/3 the size ofthe vein)

y Hemorrhages/Exudates- indicate presence orabsence

y FovealReflexa singlereflection oflight must be observed whenyou shinelight onthe fovea


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Types of Exudates:

a.hard exudate / trueexudate with clear border;lipid and lipid-laden macrophages extravasated from vessels

b. softexudates- with fluffy border;areas of infarct.

RetinalHemorrhage

Summary

y Ocularhistory was discussed includingthe differenteye complaintsy Explained the different ophthalmologic examinations,and its significancey Described thetechnique in doingthe different ophthalmologic examinationsy Discussed normalas wellas abnormal findings

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Trust inthe Lord withall yourheartand leannot in your own understanding, inall your ways acknowledgeHim,

and He will make your paths straight.

- Proverbs 3:5-6

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