1. Basic Examination of the Eye for primary healthcare providers
DR CHIN PIK KEE
FRCS Ophthal (Edinburgh), M. Med Ophthal (S’pore)
Sunway Medical Centre
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

2. Objectives To be able to detect and recognise abnormal ocular findings
To be able to describe ocular findings to a consulting ophthalmologist
To be able arrive at a diagnosis or working plan of management
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

3. Basic Torchlight Examination
The most basic equipment
Easily available
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

4. 2. Conjunctiva Sclera 1. Eyelids Eyelashes 3. Cornea 4. Pupil
5. Anterior chamber
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

5. 1. Eyelids and eyelashes Position Any inflammation?
Any discharge or crusting?
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

6. Inturned eyelid (entropion) Inflammation / dysfunction
2. Basic Eye Examination
Inturned eyelid (entropion)
Inflammation / dysfunction
Inturned eyelashes
Epiblepharon
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

7. 2. Conjunctiva and sclera
Should be white (with normal blood vessels)
Any redness?
Any swelling or growths?
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

8. Chemosis (allergy) Pterygium
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

9. Red eye – note the distribution of the hyperaemia
2. Basic Eye Examination
Red eye – note the distribution of the hyperaemia
Ciliary/circumcorneal flush
Not just “conjunctivitis”
Corneal disease
Intraocular inflammation
High intraocular pressure
Mainly peripheral
Conjunctival pathology
Ciliary flush - mainly at the limbus
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

10. 3. Cornea Should be clear, smooth, glistening Any opacity?
Any irregularity?
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

11. Foreign body Corneal ulcer Corneal opacities Corneal ulcer
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

12. Hazy cornea in acute glaucoma Corneal laceration
2. Basic Eye Examination
Hazy cornea in acute glaucoma
Corneal laceration
Large cornea in childhood glaucoma
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

13. 4. Pupil
Is it round?
Is it reactive? A normal pupil constricts in the light, dilates in the dark.
Are both pupils equal and symmetrical?
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

14. Pupil distorted or not round
Iris tear (pupil)
Iris tear (iris root)
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

15. Pupil dilated or non-reactive to light
Mid-dilated, non-reactive
pupil in acute glaucoma
Stuck-down iris (posterior
synechiae) in uveitis
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

16. 5. Anterior chamber Is the space between the cornea and iris clear?
Can the iris and pupil be seen clearly?
Is it deep?
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

17. Blood in the anterior chamber (hyphaema)
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

18. Cells or pus in the anterior chamber (hypopyon)
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

19. More Tests Anterior chamber depth Upper eyelid eversion
Extraocular eye movements
Fluorescein staining
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

20. Anterior Chamber (AC) Depth
To identify eyes with shallow anterior chambers
At risk of acute angle-closure glaucoma
Do not dilate these pupils
The space between the cornea and iris
Lens
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

21. Shine a light from the side. Look at the nasal iris.
If the nasal iris is:
bright: AC is deep
dim: AC is shallow
Iris partly in shadow – AC is shallow
Shadow
Lighted
LIGHT
Lens-iris plane
Iris diffusely illuminated – AC is deep
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

22. Shallow anterior chamber
Nasal iris in the shadow (dark)
Light shone from the temporal side
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

23. Upper Eyelid Eversion
Useful procedure to check for retained / lost contact lenses, foreign bodies etc.
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

24. Pseudomembranes in acute conjunctivitis
Foreign body, suture material
Giant papillae
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

25. Extraocular Movements
2. Basic Eye Examination
Ask the patient to look:
Right and left, up and down
Use a light, your finger or a fixation target
The eyes should move fully and equally in all directions
Limitation of eye movement may be a sign of a:
Neurological problem like brain aneurysm or tumour (life-threatening)
Orbital cellulitis (life-threatening)
Orbital fracture
Thyroid eye disease
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

26. RE unable to move to the right (brain tumour)
RE unable to move up (orbital fracture)
LE unable to move up (brain aneurysm)
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

27. direct ophthalmoscope
Fluorescein Staining
Stains abrasions, ulcers, erosions on cornea and conjunctiva
Appears green under blue light (direct ophthalmoscope or slit lamp) +
Fluorescein strip, wetted with a topical anaesthetic (e.g. Alcaine®, Tetracaine) or normal saline.
Torchlight , or
direct ophthalmoscope
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

28. Fluorescein staining + corneal opacity
= Corneal ulcer  Consult/refer to ophthalmologist
Fluorescein staining but no corneal opacity
= Abrasion or erosion
Corneal opacity, no fluorescein staining, comfortable eye
= Corneal scar
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

29. Staining is seen better under blue light
Dendritic ulcer
Herpes infection
Usually missed without fluorescein
DO NOT use steroid drops
Corneal erosions
Corneal abrasion
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

30. Testing Visual Acuity Vision testing chart (Snellen chart)
Testing distance:
6 metres (20 feet)
20D lens for magnification
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

31. Test with glasses, if used
Test one eye at a time, cover the other eye (do not press)
Note the smallest row that can be read
e.g. 6/6, 6/24, 6/60
A significant improvement with pinhole indicates refractive error
If the biggest row cannot be read, test for “counting fingers”, “hand movements” or “light perception”
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

32. Testing the Red Reflex
View the patient’s pupils through a direct ophthalmoscope
Dim the room light
Patient looks into the distance (not at the light)
Testing distance: ½ - 1 m away
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

33. An absent red reflex is abnormal
Indicates media opacity
Causes include:
Cataract
Vitreous haemorrhage (blood in the eyeball)
Retinoblastoma (eye cancer)
No red reflex (mature cataract)
Red reflex present
(no media opacity)
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

34. At well-baby clinics and vaccination visits:
Routinely check the red reflex for all preverbal children
For early detection of serious conditions like congenital cataracts and retinoblastoma
Normal
Red reflex present and equal in both eyes (no media opacity)
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

35. Tip: + Poor visual acuity Good red reflex
Brisk pupillary light reaction
VA improves with pinhole
Refractive error
Good red reflex
Brisk pupillary light reaction
VA does not improve with pinhole
Macular problem
Media opacity, e.g.,
Cataract
Vitreous haemorrhage
Poor red reflex
Brisk pupillary light reaction
Good red reflex
Poor pupillary light reaction
Advanced glaucoma
Optic nerve problem
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

36. Intraocular Pressure (IOP)
Methods of assessment
Digitally, by feel (do not do this if there is a penetrating eye injury)
Goldman tonometer
Air puff tonometer
Tonopen
Icare tonometer
Perkin’s tonometer
Historical:
Shiotz tonometer
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

37. Pupillary Dilation May be needed to allow a better view of the retina
2. Basic Eye Examination
May be needed to allow a better view of the retina
Diabetic retinopathy screening
ROP screening
Dilating eye drops
For neonates and infants - Cyclomydril
For others
Tropicamide 1% (lasts 4 – 6 hours)
Phenylephrine 2.5% (lasts 1 – 3 hours)
Caution in hypertension, ischaemic heart disease
Risk of causing acute angle-closure glaucoma
Avoid in shallow anterior chambers
Caution in hyperopic patients
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

38. PRACTICAL Equipment needed: 1. Snellen chart, occluder, pinhole
2. Good penlight
3. Direct ophthalmoscope
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

39. Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

40. Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

41. Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

42. Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

43. Thank you
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak