2 Learning ObjectivesAt the conclusion of this presentation, the participant should be able to:Understand how to perform the basic eye examUnderstand the differences between sight-threatening disorders and those that can be managed safely by the primary care physicianDiagnose common ophthalmic disease
3 The basic eye exam The tools: visual acuity chart near card bright lightdirect ophthalmoscopetonopenslit lampeye drops: topical anesthetic, dilating dropsfluorescein 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)
7 Visual acuityTypically measured by Snellen acuity but there are many optotypes (letters, tumbling E, pictures)May be tested at any distanceRecorded 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 patched20/20 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 occluderCentral rays of light do not need to be refracted
10 Sensory visual function Stereopsis (perception of depth), contrast sensitivity, glare, color visionThe 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 examRelative 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 testIndicates unilateral or asymmetric damage to anterior visual pathways (optic nerve or extensive retinal damage)
14 Ocular alignment & motility Strabismus is misalignment of the eyesImportant to recognize in children to prevent development of amblyopiaPhoria is latent tendency toward misalignmentTropia is manifest deviation (present all the time)
15 corneal light reflexNormal or straightExotropiaEsotropia
16 corneal light reflexBe aware of pseudoesotrpoia in children with epicanthal folds
17 cover testingCover-uncover or alternating cover testing can reveal strabismus as non-occluded eye fixates on object
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 ManifestionOptic 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 immunoglobulins6% are EuthyroidEyelid retraction most common ophthalmic feature at 90%, proptosis 60%, strab 40%<2% develop optic neuropathy
45 Thyroid Eye DiseaseA 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.