Eyes

 The Fundoscopic Exam

• First, prepare the patient, tell them you must get pretty close to them

• Next, darken the room to allow pupils to dilate

• Use the opthalmascope

  • It is important to use the same hand side as the eye you’re examining in the patient

• Position the patient well and do not cross midline

  • Tell them to focus on an object just above your shoulder

• Examine systematically in order as follows

  • Optic disc

    • Look at color and disc to eye ratio, then the retina

  • blood vessels

  • macula

  • fovea

Glaucoma (Open-Angle, Closed-Angle)

• The glaucoma dx needs measurements that the naked eye can’t see like intraocular pressure

• In open-angle glaucoma assesment

  • history - patients may be asymptomatic until advanced stages

  • Determine risk factors such as

    • fam hx, age >40, diabetes, htn      

  • Symptoms

    • Gradual peripheral vision loss, tunneled vision, decreased visual acuity

  • Physical exam

    • measure intraocular pressure

      • Elevated would be great that 21 (>21)

    • perform optic nerve exam

      • cup to disc ratio above (.6) and can have optic disc pallor

    • Visual field testing will show signs of peripheral visual field loss called Arcuate Scotomas are common in open angle glaucoma

• Closed Angle Glaucoma

  • Ask about a sudden onset of symptoms

  • Closed is going to be sudden and not gradual

  • Sudden severe eye pain, headache, blurred vision, halos around lights, nausea, vomiting

  • Risks are female sex above age 40 and hyperopia (farsightedness)

• Physical exam may show optic nerve cupping, but it can be difficult to see

• Differential diagnosis for glaucoma should include

  • Conjunctivitis - redness of the conjunctivae, tearing, and discharge

  • Foreign body - photophobia, normal intraocular pressure

  • Optic neuritis - painful lateral gaze, unilateral symptoms, younger age

• Treatment of glaucoma

  • Acute symptoms should get sent to an ophthalmologist

  • Chronic symptoms

    • Latanoprost (prostaglandin analogue) reduced IOP by increasing outflow of fluid from the eye

    • Timolol decreases the production of aqueous humor to lower IOP

    • Brimonidine (alpha agonist) - reduces IOP by decreasing the production of aqueous humor and increasing the drainage

Cataract

• assess symptoms    

  • hx

    • gradual onset, difficulty with night vision, increase in glare or bright lights

    • ask about difficulty with judging distances or ADLs, ask about diabetes, htn, or eye surgeries or trauma

  • Physical exam'

    • Look for opacity or a cloudy lens, the pupil can look greyish or bluish

    • The red reflex should be diminished or abnormal. Some areas will be reduced

    • Check visual acuity

    • Differentials

      • Glaucoma - if the IOP is raised, because it is not raised in glaucoma

      • Macular degen - but this causes central vision loss

  • Treatment

    • Patient education

    • Supportive care

      • Address dry eyes

      • Get the correct contacts

    • Refer to an ophthalmologist

Conjunctivitis (Allergic, Bacterial, Viral)

• Assessment

  • ask about the symptoms when they happen, what time of day, did they have a cold, etc…

  • Palpate pre-auricular or submandibular lymph nodes, which may be swollen

  • How to tell the difference

    • Allergic - will typically have a history of allergies and bilateral symptoms

    • Bacterial - initially unilateral

    • Viral - may have symptoms of upper respiratory infections

• Treatment

  • Bacterial - Antibiotic drops or ointment, such as polymyxin-bacitracin-neomycin-erythromycin treatment, can be used for a few days to a few weeks

  • Viral - focus on symptom relief, the symptoms will resolve in 1-2 weeks

  • Allergic Conjuctivitis - antihistamine or mast cell stabilizer drops like olopatodine or ketotifen

Hordeolum (looks like a stye)

• Assessment - ask about onset, is the pain localised to eye eyelid, tenderness, swelling, ask if they have had a hx of these, if they share towels

• Physical exam - inspect eyelid, check if the hordeolum is external or internal

• Differentials

  • Chlazion - will develop more gradually and is a painless firm nodule

  • Preseptal Cellulitis - rapid onset of eyelid swelling where in hordeolum its more localized

  • Basal cell carcinoma is more painless, slow growing and sometimes ulcerated lesion that mimics a chronic chalazion and can be indurated

• Treatment

  • Pain is at lid margin and between follicles use clean warm soaks and topical erythromycin or bacitracin/polymyxin B

  • Avoid contact lenses

Chalazion

• Looks like a hordeolum but bigger and developed more gradually, as well as a painless, firm nodule, but can be tender

• Treatment

  • Warm soaks, with erythromycin and cefalexin PO

Macular Degeneration

• Drusen - Small yellow areas that are found in the fundoscopy exam

• Symptoms are going to include

  • central vision loss, blind spot in the central field

• Impact on ADLs

  • Snellen chart, areas

• Treatment

  • Determine the stage

    • If it is intermediate or advanced, refer out

Strabismus

• eyes are not properly aligned. Can be intermittent or constant

• Ask about family hx or how long it has happened or if it affects their ADLs

• Perform cover/uncover test,

  • Hirschberg test - quick and qualitative assessment of ocular alignment, particularly useful in children

    • ask patient to fixate on a target like a penlight held at a distance

  • Observe the corneal light reflex

  • Treatment

    • Corrective lenses

    • Orhoptic excersices, patching therapy, botox

Hypertensive Retinopathy

• gives the arterials in the eye a copper wire appearance

• Also will show “knicking” or indentation of the veins

• Flame-shaped hemorrhages

• soft and hard exudates like soft and well-defined yellow areas

• assessment

  • ask for diabetes, renal disease, cardiac disease, htn, symptoms of blurred vision, assess vitals and bp and assess control of htn

• treatment

  • Blood pressure control

  • treat underlying conditions like diabetes or renal disease

  • refer

Red flags of lessons

• Loss of vision needs quick intervention or referral

• Red eye with mildly dilated pupil, poorly responsive to light may be closed-angle glaucoma, which can lead to blindness

• New onset floaters or flashes of light may be indicative of posterior vitreous detachment or retinal tear

Fluorescein Dye Procedure

• Tell the patient what you are doing

• Instill 1 to 2 drops of fluorescein dye into the conjunctival sac

• Advise the patient to blink several times

• expect a yellow tint on their eye

• Assess for corneal abrasion or foreign body

• vision may be blurry for a bit after