PCCR I: The Eye Exam

Nystagmus

fine rhythmic oscillation of the eyes
(when assessing conjugate mvmts)

Pupil is unilat large, with slow/absent reaction to light, and slow tonic constriction during near vision due to parasyp DEnervation
Slow accommmodation → blurred vision

Tonic Pupil (Adie pupil)

affected pupil is large and fixed.
Ptosis of upper eyelid
lateral deviation of eye downward and outward

Oculomotor Nerve (CNIII) Paralysis

Label Structures

Label Optical Strucutres

Label Optical Structures

Label Optical Structures

Red Flag Symptoms

Sudden change in vision in red eyes

• pathology: Glaucoma, Retinal Detachment

small, unilat, slow-dilating pupil
ipsilateral ptosis
ipsilateral anhidrosis
anisocoria >1mm

Horner Syndrome (caused by lesion in sympathetic pathways OR congenital)

Hx: blurred vs double vision

Blurred vision: hazy or out of focus; loss of sharpness or clarity

• ACUITY~

Diplopia (double vision): perception of two images

• monocular: optical problem (cornea or lens)

• binocular: alignment problem (weakness/paralysis of one or more extraocular muscles EOMs)

Hx: Eye Redness or Pain

How long since?

Associated discharge, itching, vision changes?

environmental exposures?

pupils small and irregular, usually bilat
constrict w/ near vision and dilate w/ far vision (NORMAL)
no reaction to light

Argyll Robertson Pupils (small, irreg pupils)
Caused by: neurosyphilis, rarely diabetes

HX: eyelids

infection ptosis, growths, masses, itching

Hx: Cataracs

type (congenital, senile, diabetic, traumatic) and treatments?

Hx: Trauma

Type

Management

Outcome

PMH

eye surgery: condition, type, date, outcome

Chronic illness: glaucoma, diabetes, atherosclerotic cardiovascular disease (ASCVD), hypertension, thyroid dysfunction, autoimmune disease, human immunodeficiency virus (HIV), inflammatory bowel diseases

Medications: steroids/ hydroxycholorquine

FH

Retinoblastoma, glaucoma , macular degeneration, DTM, HTN, autoimmune diseases, cataracts, retinal detachment

Personal/Social Hx

Employment/Activities (EXPOSURE): use of protective eyewear?

Use of corrective lenses:

• type? ( contacts/glasses) → last changed? How long? adequacy of corrected vision? methods of cleaning/storage? freq of disposal, insertion and removal procedues? Sleeping in contacts?

Date of last eye exam?

Hx of smoking (risk for: cataracts, glaucoma, macular degenration)

Esotropia

light reflection → cover-uncover test

exotropia
light reflection → cover-uncover test

hypertropia

light reflection → cover-uncover test

hypotropia

light reflection → cover-uncover test

lid lag

test by having pt follow finger as you move quickly from ceiling to floor from midline
DEF: upper eyelid overlaps the iris slightly throughout mvmt: visible rim of sclera above iris w/ downward gaze
indicative of thyroid eye disease

Extraocular Muscles

H test (12-14”)
Assess: nystagmus, convergence, lid lag

Pupillary Reaction

direct (optic N/afferent neurons) vs consensual reaction (oculomo N/efferent neurons)
Swinging flashlight test
Pupillary Near Reaction

Pupillary Near Reaction
10cm from near
indicative of diabetes, syphilis no response to direct light BUT constrict during accommodation

elev intracranial pressure cause intraxonal edema along optic N → engorgement and swelling of optic disc
loss of venous pulsation; ↑disc vessels and visibility, curve over borders of disc; disc swollen w/ margins blurred; NO physiologic cup

papilledema (intracran mass, lesion, hemorrhage, meningitis)

incr intraocular pressure w/in eye leads to incr cupping (bked depression of disc) and atropy. BASE of enlarged cup is pale
death of optic N fibers → lose tiny disc vessels

Glaucomatous Cupping

physiologic cup enlarged, occu >1/2 disc’s diameter.
NO tiny disc vessels

Optic Atrophy (optic neuritis, MS, temp arteries)

small, liner, flame-shaped, red streaks

superficial retinal hemorrhages
(severe HTN, papilledema, occlusion of retina vein)

blood escapes potential space b/t retina and vitreous (larger than retina hemorrhage, ANT retina)

Preretinal Hemorrhage
(sudden incr in intracranial pressure)

small, rounded, slightly irreg red spots (dot/blot hemorrhages)

Deep Retinal Hemorrhages
(diabetes)

tiny, round, red spots in/around macular area
minute dilatations of v small retinal vessels

Microaneurysms
(HALLMARK of diabetic retinopathy)

formation of new blood vessels → more numerous, tortuous, and narrower than neighbor (disorderly looking red arcades)

Neovascularization
(Common feat. of proliferative stage of diabetic retinopathy)

white/grayish, ovoid lesions. microinfarcts of retinal nerve fiber layer

Soft Exudates: Cotton Wool Spots
(extruded axoplasm from retinal ganglion cells → HTN, diabetes, HIV, virus…)

lipid residues of serous leakage from damaged capillaries
creamy/yellowish, lesions w/ well-defined borders. Small, round

Hard Exudates

(diabetes and vasc dysplasias)

yellowish tiny-small round spots in retina. edges soft or hard. Dead retinal pigment epithelial cells

Drusen
(normal aging and age-related macular degeneration)

UV-related eye injuries

skin cancers on eyelids
↑ cataract risk
direct: solar retinopathy

prevent: sunscreen on face and eyelids; eye protection against UV radiation

American Academy of Ophthalmology - visual impairment

comprehensive screening medical eye exam for all adults (visual acuity & visual fields, fundoscopic exam, measurement of intraocular pressure)
freq based on age and at-risk

American Academy of Ophthamology - glaucoma

leading cause of visual impairent and blindness
periodic glaucoma testing, w/ baseline exam starting 40yr and possible earlier for at-risk pt w/ known FHx

diffuse dialation of conjunctival vessels w/ redness that tends to MAX peripherally

Mild discomfort, vision fine, discharge watery/mucoid/mucopurulent

Conjunctivitis

(bacterial, viral, other infectious; highly contagious; allergy; irritation)

deeper vessels radiated from limbus dialated, creating reddish-violet flush
eye possible diffusely red

mod-severe pain, ↓vision, discharge water/purulent; infection → corneal opacity

Corneal Injury/Infection

(abrasions, other injuries, viral and bacterial infections)

redness more concentrates around limbus w/ deeper vessels
mod/aching/deep/photophobia pain, ↓vision, NO discharge, pupil SMALL/IRREG,

Acute Iritis

(syst infection, Herpes zoster, TB, autoimmune disease)

leakage of blood outside vessels (homogenous, sharply demarcated, red area)

benign

resolves over 2 wk

Subconjunctival Hemorrhage

(trauma, bleeding disorder, sudden incr in venous pressure)

diffuse redness, w/ steamy cornea and marked circumcorneal flush

severe/aching/deep/severe photophobia pain, ↓vision, NO discharge, PUPIL dilated/fixed, cornea steamy/cloudy

Acute Angle Closure Glaucoma
(acute incr in intraocular pressure → EMERGENCY)

occl of branch of central retinal artery

ischemia of optic nerve can produ sim defect

Horizontal Defect

lesion of optic nerve and eye → unilat monocular blindness

Blind Right Eye (Right Optic Nerve)

Lesion at optic chiasm (ex pituitary tumor). Vision loss in temporal ½ each field

Bitemporal Hemianopsia (optic chiasm)

Lesion of optic tract, interrypts fibers orig on SAME side of both eyes

Left Homonymous Hemianopsia (right optic tract)
vision loss ~ homonymous; half of each field (hemianopsia)

partial lesion of optic radiation in temporal lobe. Only portion of nerve fibers (“pie in the sky”)

Homonymous Left Superior Quadrantic Defect (R optic Radiation, Partial)

complete interruption of fibers in optic radiation (sim to visual defect in lesion of optic tract)

Left Homonymous Hemianopsia (R Optic Radiation)

drooping of upper eyelid (involutional, myogenic, neurogenic, mechanical etiologies)

Ptosis
senile ptosis (involutional changes)
congenital ptosis (myogenic factors)

lid margin inward

Entropion (elderly common)

lower eyelid margin turns outward, exposing palpebral conjunctiva

poor eye drainage and tearing

Ectropion (common elderly)

wide-eyed stare - visible rim of sclera b/t upper lid and iris
eye protrusion -

Lid Retraction and Exophthalmos

+lid lag HYPER THYROIDISM (fine tremor, moist skin, HR >90bpm)

THYROID EYE D - autoreactive T-lymphocytes (retraction, lid lag, diplopia, dry eyes, pain, tearing)

UNILAT exophthalmos → thyroid eye D, trauma, orbital tumors, sinus issues, granulomatous disorders

harmless yellowish trangular nodule in bulbar conjunctiva. either side of iris (nasal→temporal)

RF: aging

Pinguecula

benign, typ painless localized ocular inflam of episcleral vessels

vessels appear movable, may be nodular/show only redness and dilated vessel

Episcleritis

painful, tender, red infection @ inner or outer margin or eyelid (S.aureus)

inner margin - obstructed meibomian gland

outer margin - obstructed eyelash follicle

Stye (Hordeolum)

Subacute nontender, typ painless nodule → blocked meibomian gland

may become acutely inflamed (points inside lid)

Chalazion

Slightly raised, yellowish, well-circumscribed cholesterol-filled plaques along upper/lower nasal portions of 1 or 2 eyelids

½ have hyperlipidemia; common w/ biliary cirrhosis

Xanthelasma

chronic inflam of eyelids @base of hair follicles (S.aureus)

Blepharitis