1. Macleod’s 14th edition – chapter 8 Asal Alkum
The visual system
Macleod’s 14th edition – chapter 8
Asal Alkum

2. Anatomy and physiology
Eye is situated the in the Bony orbit.
Protected by: Eyelid ( from injury / maintain tear film)
*Upper lid: elevated by 1- levator palpebrae superiosis.(Cranial Nerve lll)
2-Mular muscle(sympathetic system)
*eyelids Closure : mediated by orbicularis oculi(cranial nerve VII)
The orbit houses the :
1- eyelid 2-lacrimal apparatus 3-blood vessels 4-autonomic nerve fibers 5-cranial nerves (ll , lll , lV , Vl) 6- six extra ocular muscles.
The contents are cushioned by orbital FAT.

3. Anatomy and physiology
The conjunctiva : is a thin mucous membrane lining the posterior aspects of the eyelid ,, reflected at the superior and inferior fornices on the surface of the globe .
-Coated in a tear film(oil &aqueous & mucin layer) that protects and nourishes the ocular surface.

4. eye The eye ball 25mm in length. Comprises three distinct layers :
1- Outer fibrous layer
2- Middle vascular layer ( uveal tract)
3- Inner neurosensory layer

5. Extraocular muscles
6 extraocular muscles  all innervated by oculomotor nerve except:
Lateral rectus innervated by the abducent nerve.
Superior oblique innervated by the trochlear nerve.

6. Refractive elements the major refractory elements:
1-Tear film 2-cornea 3-crystalline lens
-cornea posses The greatest refractive power and the main refracting element of the eye
lens .. Additional controllable refraction , causing the light to focus on the retina
When light is :
Precisely focused on the retina … emmetropia
Focus point falls behind the retina .. Hypermetropia ( long sightedness) .. Eye is too short
Focus infront of the retina .. Myopia (short sightedness) .. Eye is too long

9. Pupillary pathway Pupil  Control the amount of light entering the eye
Intensity of the light determines the aperture of the pupil .. Via autonomic reflexes :
1)Pupillary constriction : by parasympathetic nerves
2) Pupillary dilation : by sympathetic nerves

10. The history COMMON PRESINTING SYMPTOMS : 1)Altered vision 2)Pain
3)Red eye
4)Double vision
5)Discharge
6) Swollen eye

11. Altered vision Vision altered by intraocular diseases which leads to :
change in the optical or refractive properties of the eye
Prevent the incident light rays from being clearly focused on the retina
Alternatively, it may results from extraocular factors associated with :
Damage to the visual pathway , which runs from the optic nerve to the optical lobe

12. Altered vision Establish whether the change in vision is :
Sudden 2) gradual
- Both of them have their own specific set of differential diagnosis
vision may be not just reduced but also distorted …
this results from disruption to the normal structure of the macula , the central part of the retina ..
The most common cause is macular degeneration
but also may frequently stem from an epiretinal membrane ,vitreous traction or central serous retinopathy

13. Altered vision Flashes and floaters …
This results from disturbance of the vitreous and the retina ,
occurring most commonly in posterior vitreous detachment
Ususally found in older patient as the vitreous gradually
degenerates and liquefies , causing it to peels from the retina
The vitreous is attached to retina in certain regions , in these
regions the vitreous either :
1)detaches with traction … resulting in flashing light
2) Detaches by tearing the retina .. Releasing retinal pigment cells
Patient will see either of these as floaters

15. Altered vision
Haloes : are colored lights seen around bright light Occurs
with corneal edema and mostly associated with
angle-closure glaucoma

16. Altered vision
What to ask about when you have a patient with altered vision :
1)Did it start sudden , or gradually ?
2)How the vision is affected (loss/cloudy/floaters / distortion)?
3) One or both eyes that are affected ?
4) The whole or only part of the visual field affected ?
5) If partial . Which part of the visual field is affected

17. pain Ask: 1)when it began ? 2)Anything started the pain
3)Character of the pain
4)severity?
5)Exacerbation and relieving factors
6)Associated symptoms
Cornea is one of the highly innervated regions of the body
When corneal nerves are activated … leads to
1)Pain 2)sensation of a foreign body 3)reflex watering 4) photophobia

18. Red eye
The eye is covered with a network of vessels in the conjunctiva ,episclera and sclera .
Ciliary vessels are also found around cornea
Dilation or hemorrhage
uveitis , in acute angle closure glaucoma and corneal irritation … the ciliary vessels around the cornea become more prominent ( ciliary flush)
The appearance is distinct from conjunctivitis , in which there is blanching of vessels towards the cornea

20. Red eye Ask: 1)If the eye is painful or photophobic?
2)Vision is affected?
3)Recent trauma?
4)Eye is itchy?
5)Any discharge?
6)Any recent contact lens wear or foreign body exposure?

21. Double vision
Whether it is : 1)Monocular .. Results from intraocular disease in one eye 2)Binocular .. Results from imbalance in eye movement Ask: 1)Occurs in one or both eyes? 2)Character ? Whether Images seen side by side ? One above the other? Or at angle ? 3)recent trauma

22. discharge Ask: Increase in discharge from the eye results from :
1)Increase in production
2) Decrease in drainage from the oclear surface
Irritation of corneal nerves activates cranial nerve V1 and results in reflex tearing response.
Tears normally drain through the punctum at the medial end of the lower eyelid into nasolacrimal duct .. Which opens below the inferior turbinate into the nasal cavity .
Ask:
1)Discharge clear? opaque?
2)Associated pain ?foreign body sensation? Itchiness?
3)other abnormalities ? Such as red eye ?

23. Swollen eyes
Orbit is an enclosed structure except anteriorly, so any swelling inside the orbit will results in :
Anterior displacement of the globe (Proptosis)
Ask
unilateral or bilateral
Acute ? Chronic ?
Painful?
Itchiness? Irritation ?
Associated with double vision?
There are many causes

24. Past ocular history
Ask 1)Any known opthalmic conditions 2)Ask specificcaly about having amblyopia (reduction in vision in one eye from childhood) .. this may limit best-corrected visual acuity 3) If the patient wears glasses or contact lenses 4)Last time they had their eyes checked for refractive correction 5)Any previous eye operation that may affect vision

25. Past medical history
Focus on systematic diseases that can affect the eyes directly or as a side effect of treatment :
diabetis or HTN .. Especially in the context of visual loss of double vision
Thyroid disease.. Red, swollen eyes, double vision
asthma or COPD or peripheral vascular disease if starting glaucoma medications

26. Drug and allergy history
The eyes may be affected by medications for other conditions .. Like glaucoma exacerbation by conjunctival absorption of nebulished anticholinergic drugs in copd
Medications for the eyes ( like beta blocker eye drops )can aggrevate other conditions like asthma
Ask about a History of fever or allergy .. If the patient has itchy eyes

27. Family history Several eye diseases have an inherted predisposition
Ask:
1)History of glaucoma in first order relatives
2)Genetic diseases affecting the eye ... Includes retinitis pigmentosa
3)Thyroid eye disease … may have positive family history of autoimmune disease

28. Social history
Visual impairment has a wide range of effects on daily life
Ask:
1)Dailly activity require good vision … reading/Tv /sport/hobbies/…
2)Driving
3)Occupation .. Certain professions including drivers of heavy good vehicles / pilots requirespecific visual acuity criteria
4)Smoking and alcohol use… this may affect vascular and optic nerve function within the eyes

29. Physical examination General examination :
Carefully and systematically examine:
1)Posture and gait
2)Head position
3)Facial asymmetry and dysmorphic features
4)Eyelid position and periocular skin
5)Position and asymmetry of gaze (any squint/strabismus)

30. Physical examination Visual acuity:
Mandatory to assess in all patients.
Each eye should be assessed separately .. The most common method of testing distance visual acuity is using snellen chart ( displays a random selection of letters at diminishing font size in successive lines )
Ask:
to wear their distance spectacles if they require them .. Near/ reading spectacles should be worn only when testing reading vision

32. Examination sequence
If the patient cannot see the largest font, reduce the test distance to 3 metres, then to 1 metre if necessary.
If they still cannot see the largest font, document instead whether they can count fingers, see hand movement or just perceive the difference between light and dark.
If the patient cannot read down to line 6 (6/6), place a pinhole directly in front of the eye (with the patient keeping their usual spectacles on, if they wear them) to correct any residual refractive error
if the visual acuity is not improved with a pinhole, this indicates the presence of eye disease not related to the refractive apparatus alone, such as retinal or optic nerve pathology.
Assess near vision with a similar test using text of reducing font size held at a comfortable reading distance. It is important to consider the need for reading spectacles in patients over the age of 40 years because of presbyopia (age-related deterioration in near vision).

33. Physical examination Orbit and periorbital examination:
• Observe the face and orbit for asymmetry and any obvious abnormality, including swelling, erythema or any other skin changes.
• Look for any abnormality in the position of the lids and ptosis
• Look for any asymmetry in the position of the eyeballs. Eyeball protrusion (proptosis) is best detected by looking down on the head from above.
• Palpate around the orbital rim and orbit, looking for any masses.
• Check eye movements .
• Use an ophthalmoscope to look for optic disc swelling from compression.

34. Physical examination Direct and consensual light reflex
pupils
Examine
1) inspect generally for squint and ptosis
2)Examine pupil shape and symmetry .
Physiological anisocoria (unequal pupil size ) is seen in 20% of population .
Direct and consensual light reflex
Examination sequence
With the patient fixating on a point in the distance and in ambient lighting, shine a bright light from the temporal side into one eye and look for constriction of the ipsilateral pupil.
• To test the consensual reflex, assess the pupil response in the contralateral pupil when light is directed towards the ipsilateral pupil. Repeat for the other pupil

35. anisocoria Examination sequence
The eyes should be assessed to determine which is the abnormal pupil.
Examination sequence
• With the patient fixating at a point in the distance, increase and decrease the illumination and look for any change in the degree of anisocoria
If the degree of anisocoria is greater in brighter lighting, then it is the larger pupil that is abnormal; if it is more pronounced in dim lighting, the smaller pupil is the abnormal one.
An equal degree of anisocoria
in all levels of lighting indicates
physiological anisocoria.

37. Relative afferent pupillary defect
is an important clinical sign that occurs when disease of the retina or optic nerve reduces the response of the eye to a light stimulus
Testing for RAPD is an extention of the direct and consensual light responses
Examination sequence
• Use a bright light source
• Move the light briskly from one eye to the other, but place it on each eye for a minimum of 3 seconds.
In normal patients, this results in symmetrical constriction of both pupils. In RAPD, light in the affected eye causes weaker constriction (apparent dilatation) compared to light shone in the normal eye

38. accommodation Examination sequence
• Ask the patient to look at a close fixation target (do not use a light source) after fixating on a distant target.
• There should be constriction of the pupil on near gaze
• Failure to constrict to light but constriction on near gaze is referred to as
light-near dissociation.

39. Visual fields
The normal visual field extends 160 degrees horizontally and 130 degrees vertically.
Fixation is the very centre of the patient’s visual field.
The physiological blind spot is located 15 degrees temporal to the point of visual fixation and represents the entry of the optic nerve head into the eye.
The aim of the visual field examination is to test the patient’s visual fields against your own (making the assumption that you have normal visual fields). The visual field can be tested using the fingers for gross examination. Finer examination can be performed using a small hatpin.

41. • Check visual acuity and ensure that the patient has at least enough vision to count fingers.
• Sit directly facing the patient, about 1 metre away.
• With your eyes and the patient’s eyes open, ask the patient to look at your face and comment on whether they have any difficulty seeing parts of your face.
• Ask the patient to keep looking straight at your face. Test each eye separately. Ask the patient to close or cover one eye and look directly across to your opposite eye; you should also close your other eye.
• Hold your hands out and bring an extended finger in from the periphery towards the centre of the visual field. For an accurate assessment of the patient’s fields, it is vital that the testing finger is always kept in the plane exactly halfway between yourself and the patient.
Wiggle your fingertip and ask the patient to point to it when they first see it
If the patient fails to notice your finger when it is clearly visible to you, their field is reduced in that area.

42. • Test all four quadrants separately.
• More subtle visual field defects can be elicited using a small white hatpin or a white Neurotip. With the patient looking directly at your eye, bring the white target in from the periphery to the centre (again always in the plane halfway between you and the patient). Ask the patient to say when they first see the target.
• Undertake this for all four quadrants, testing each eye separately.
• To assess very early visual field loss, repeat the same test using a red hatpin or a red Neurotip (Fig. 8.14)
• It is important to show the patient the red target and ask them to report what colour they see. A dull or pale red suggests colour desaturation, which may indicate optic nerve dysfunction.
• When testing each quadrant with a red target, be sure to explain to the patient that they should say when they first see that the target is red and not when they first see it. The target may be visualised before they appreciate the red colour.
• To test the blind spot, place a red-tipped target equidistant between the patient and yourself at the visual fixation point.
• Move the target temporally until it disappears. • Then move the target slowly up and down, as well as from side to side, until it reappears. This allows you to compare the patient’s blind spot with yours

43. Ocular alignment and eye movement
The eyes are normally parallel in all positions of gaze except for convergence.
Any misalignment is referred to as a squint (strabismus).
Squints are described as manifest (tropia) if present with both eyes open, or latent (phoria) if revealed only by covering one eye.
In addition, they can be concomitant (where the angle of squint remains the same in all positions of gaze) or incomitant (where the angle of squint deviation is greatest in a single position of gaze).
The latter is commonly the result of paralysis of particular extraocular muscles

44. Detection of squint
• Sit directly facing the patient, approximately 1 metre away and at a similar height.
• Check visual acuity as part of the examination.
• Look for any abnormal head posture such as head tilts (seen in cranial nerve IV palsy) or head turns (cranial nerve VI palsy). These signs may be subtle.
• Hold a pen torch directly in front of the patient and instruct them to look at the light. Observe the reflection of the light on the cornea in relation to the pupil. The reflections should be symmetrical between the two eyes.
Ask the patient if they see a single or double light.
If they see double, this may indicate the presence of a squint, but not seeing double does not exclude a squint. If the reflection is on the nasal aspect of the pupil in one eye, this suggests that the eye is deviated outwards and is described as an exotropia

45. To confirm the presence of a squint, perform the cover/ uncover test:
• Ask the patient to look at the pen torch at all times and then cover one eye.
• Look at the uncovered eye for any movement. It may be helpful to repeat this several times.
• Inward movement of the uncovered eye suggests that it was positioned abnormally outwards and is described as an exotropia (divergent manifest squint).
• Conversely, if the eye moves outwards when the contralateral eye is covered, this suggests that it was abnormally positioned inwards and is described as an esotropia (convergent manifest squint).
• Repeat the cover/uncover test for the other eye.
Failure of an eye to move despite an obvious corneal light reflex may indicate that the eye has such poor vision that it cannot take up fixation or else it is restricted from moving.
The alternating cover test involves covering the eyes alternately and quickly while the patient is fixated on the pen torch. Leave the cover on each eye for about 2 seconds but move between the eyes in less than 1 second. The movement is repeated multiple times. This test will help to elicit latent squint.

46. Ocular movements
• In the same seating position, ask the patient to look at a target or pen-torch light about 50 cm away. • Ask them to say if and when they experience diplopia. • Starting from the primary position, move the target in the six positions of gaze and up and down. • If diplopia is present, ask whether this is horizontal, vertical or a combination of the two. • Determine where the image separation is most pronounced. • Look for nystagmus and determine whether the eye movement is smooth. Interpretation of any limitation of excursion is made by reference to the functions of the extraocular muscles

47. Oculocephalic (dolls eye) reflex
This reflex is the ability of the eyes to remain fixated while the head is turned in the horizontal plan
An impaired reflex indicates a brainstem abnormality.
Examination sequence
• With the patient supine, ask them to look at your face. Gently turn their head from side to side, noting the movement of the eyes.

48. ophthalmoscopy Examination sequence
The direct ophthalmoscope is a useful tool for assessing both the anterior and the posterior segments of the eye.
Pharmacological pupil dilatation is essential for a thorough fundus examination, though the optic disc can be examined sufficiently without dilatation.
Examination sequence
• Ask the patient to sit upright and look at a distant target.
• When using the direct ophthalmoscope to examine the patient’s right eye, hold it in your right hand and use your right eye to examine. Hold it in your left hand and use your left eye to examine the patient’s left eye.
• Place your free hand on the patient’s forehead and brow, as this will steady the head and improve your proprioception when moving closer to the patient with the ophthalmoscope.
• Rotate the ophthalmoscope lens to +10. This will allow a magnified view of the anterior segment. You will be able to examine the eyelid margins, conjunctiva, cornea and iris. If epithelial defects are suspected, fluorescein can be administered and a cobalt blue filter used to reveal these.

49. • To examine the fundus, dial the lens back to 0.
• With your hand on the forehead and the brow, use the ophthalmoscope to see the red reflex (red light reflected off the retina) at a distance of about 10 cm. When the red reflex is in focus, look for opacities and determine whether they are static or mobile. Static opacities are usually due to cataract changes, while mobile opacities indicate vitreous opacities.
• Slowly move the ophthalmoscope closer to the patient almost to the point that your forehead touches your thumb, which is resting on the patient’s forehead and brow
• Turn the lens dial until the optic disc comes into focus; if it does not, focus on a blood vessel.
• The optic disc can usually be located easily; if not, follow a blood vessel centrally (in the direction opposite to its branches) to locate it.
• Examine the optic disc, paying particular attention to its shape, colour, edges and cup size.
• Follow each blood-vessel arcade and examine each of the retinal quadrants.
• To examine the macula, ask the patient to look directly at the light.
The normal retina looks different in Asian and Caucasian patients.
Swelling of the optic disc is a very important clinical sign. Causes of unilateral and bilateral optic disc swelling, and their distinguishing features
A variety of diseases that can damage the optic nerve cause an abnormally pale optic disc