1	The Basic Eye Exam for the Primary Care Physician Ophthalmology Section Introduction to Clinical Medicine Kenn Freedman M.D.
2	8 Point Eye Exam Ophthalmologists Visual Acuity Pupils Confrontational Visual Fields Ocular Motility Intraocular Pressure External Exam Slit Lamp Exam Funduscopic Exam
3	Eye Exam Primary Care Physician Visual Acuity Visual Fields Ocular Motility Pupils External Exam Eyelids/ Adnexa Anterior Segment – Cornea Funduscopic Exam Red Reflex Disc, Retina
4	Eye Anatomy
5	Visual Acuity When we as Ophthalmologists measure visual acuity – we want to know the best corrected vision (After correcting for optical errors) If they cannot be corrected to 20/20 then we need to look a possible pathologic condition to explain their subnormal vision
6	Visual Acuity
7	Checking Visual Acuity with the NEAR CARD Hold at 14 inches If patient is older than 40 years old they may need some plus (+) power to be focused up close e.g. their bifocals
8	If they cannot read far down the chart, or make out only the biggest of letters, you might suspect … Cataract Diabetic Retinopathy Macular Degeneration Amblyopia Etc.
9	Refractive Errors
10	Refractive Errors Ammetropia Myopic – Near sighted Hyperopia – Far sighted Astigmatism – non-spherical
11	Far sighted Near sighted
12	Ammetopic
13	Myopic Hyperopic (Near sighted) (Far Sighted) (-) minus power (+) plus power lenses needed lenses needed
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15	Astigmatism
16	Astigmatism
17	Visual Fields Peripheral Vision Peripheral Retina
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19	Confrontational Visual Fields Patient covers one eye at a time Fixates his vision on your nose Hold up fingers up to count in each quadrant
20	Confrontational Visual Fields Patient covers one eye at a time Fixates his vision on your nose Hold up fingers up to count in each quandrant
21	Projections of Retinal Ganglion Cells
22	Projection from LGN to Occipital Cortex Optic Radiations Via Temporal lobe (Meyer’s Loop) And via Parietal lobe
23	Optic Chiasm
24	Processing of the Image Image is re-inverted by brain Left and right visual fields are split between the two sides of the brain The right side of each field goes to the left The left side of each field goes to the right
25	Visual field
26	What Things Produce Visual Field Defects ? Retinal Lesions Macular Degeneration Optic Nerve Lesions Optic Neuritis, Glaucoma Lesions of the Optic Chiasm and Beyond Tumors, Strokes, Trauma, etc.
27	Visual Field Defects Related to Location of Lesion
28	Computerized Visual Fields
29	Automated Visual Field
30	Left Homonymous Hemianopsia due to Right Occipital Stroke
31	Left Homonymous Hemianopsia
32	Right Occipital Infarct
33	Left Homonymous Defects
34	Bitemporal Hemianopsia
35	Bitemporal Defect (pituitary tumor)
36	Unilateral Visual Field Defect
37	Remember
38	Left Inferior Quandranopsia
39	Projection from LGN to Occipital Cortex Optic Radiations Via Temporal lobe (Meyer’s Loop) And via Parietal lobe
40	Visual Field Defects Related to Location of Lesion
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42	Examination of the pupils PERRL P Pupils E Equal R Round RL Reactive to Light
43	Patient with equal pupils
44	Horner’s Syndrome (Ptosis, Miosis and Anhydrosis)
45	Sympathetic Pathways to the eye
46	Anisocoria (unequal pupils) Horner’s Syndrome Third Cranial Nerve Palsy Damage to the Iris and Pupil Eye Trauma Surgical Trauma
47	Irregular pupils Argyl-Robertson Possible other manifestation of CNS disease BUT most commonly due to Intraocular Congenital Anomaly Inflammation Trauma Surgery
48	Irregular Pupil after IOL implantation
49	Pupillary Light Reflex
50	Pupil Light Reflexes Direct Response – constriction of pupil when light shined into that eye Consensual Response – constriction of pupil of non-stimulated eye
51	Consensual Response of Pupils to Light In normal subject Both Pupils will constrict equally to light shined in one eye Basis for Swinging Flashlight test Marcus Gunn (Sign of possible optic nerve disease)
52	Poor Pupil Reaction to Light Diabetics Neurologic Disease Optic Nerve Disease Sign of possible serious ocular problem Acute Angle Closure Uveitis Damage to Pupil from Surgery Trauma
53	This red eye may be more than just conjunctiviits
54	Signs and Symptoms of Angle Closure Glaucoma Symptoms: Episodes of Eye Pain Headache, Nausea, Vomitting Blurred Vision, Halos Red Eye, Dilated Pupil Signs: Red Eye (Injection of vessels) Cloudy Cornea Mid-dilated, non-reactive pupil
55	Ocular Motility Eye Movement problems can be a sign of systemic disease or help to localize a neurologic lesion
56	Extraocular Muscles Lateral Rectus - Sixth CN Superior Oblique – Fourth CN Medial Rectus Superior Rectus - Third CN Inferior Rectus (All the rest) Inferior Oblique Levator
57	Ocular Ductions
58	What is wrong with this patient?
59	Poor Abduction Sixth Nerve Palsy Graves Eye Disease Myasthenia Gravis Orbital Trauma
60	Sixth CN Palsy Microvascular Disease (HTN, DM) Brain or Orbital Tumor High Intracranial Pressure Post-Viral Syndrome Head Trauma
61	Esotropia
62	What does this patient have? Ptosis
63	Down and Out
64	Third Nerve Palsy Microvascular Brain Tumor Head Trauma Aneurysm
65	Young woman presented with left sided headache and drooping of her eyelid
66	Patient could not move her eye up, down or toward her nose, but she could abduct. Her pupil on the left was much larger than the right.
67	PCA Aneurysm
68	Fourth CN Palsy
69	Fourth Nerve Palsy Congenital Traumatic Microvasular Rarely due to CNS tumor
70	Loss of Adduction
71	Myasthenia Gravis
72	Graves Disease
73	EOM (MR) enlargement in Graves Disease
74	Right Sided Stroke can produce deviation of eyes to right
75	Eye Movement Problems Cranial Nerve Palsy Orbital Problems Trauma (e.g. blow out fracture) Graves Disease Myastenia Gravis or other Neuromuscular Disorders CNS lesion
76	External Exam Eyelid normals and lesions Proptosis contrast with normal Conjunctiva, culdesacs, chemosis, injection (not sclera), red eye, pterygia and pinguecula Conjunctivitis Cornea normal epithelium, fluorescein, HSV, abrasions, ulcers
77	External Exam Eyelids and Eyelid Skin Conjunctiva – inner eyelids and globe Cornea Anterior Chamber
78	Eye Anatomy: Globe Adnexal Tissues Conjunctiva Eyelids
79	“Stye” (Hordeolum)
80	Chalazion
81	Chalazion
82	Xanthalesma
83	Basal Cell Carcinoma
84	Skin Cancer Around the Eyelids
85	Basal Cell Carcinoma (Involving the Lid Margin)
86	Exophthalmos (Proptosis)
87	Pre-septal Versus Orbital
88	Cellulitis (Is it orbital or pre-septal?)
89	Orbital Cellulitis
90	Preseptal Cellulitis
91	Conjunctiva Mucosa Globe and Inner Eyelids Blood Vessels
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93	Pingueculum Pterygium
94	Red Eye
95	Conjunctivitis
96	SCH red eye
97	Sub-conjunctival Hemorrhage
98	Hyphema
99	Corneal Abrasion
100	Dendrite (Herpes Simplex)
101	Dendrite on Cornea (stained with Rose Bengal)
102	Corneal Ulcer
103	Cloudy, Hazy cornea secondary to acute high Intraocular pressure
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105	Fundus
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107	Red Reflex
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109	Leukocoria
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111	Normal Fundus and disc
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113	Cup of Optic Nerve
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115	Glaucoma (Cupping of optic nerve head)
116	Pallor (Atrophy) of Disc
117	Recognizing Swelling of the Disc Very important! Swollen disc usually means something serious! Does this patient have papilledema?
118	Optic Nerve Head Swelling
119	Papilledema Swelling of the optic discs SECONDARY TO Increased Intracranial Pressure
120	Papilledema - signs Blurring of disc margins No spontaneous pulsations of veins Elevation of disc Hemorrhages Obscured vessels
121	Blurring of Disc Margins
122	Elevation of Disc
123	Swelling of the Disc does not equal Papilledema! Just describe what you see on physical examination
124	59 year old man presented to our clinic with somewhat vague visual complaints OS
125	Malignant Hypertension By the way BP = 239/148
126	Brain Tumor
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129	Summary CHECK VISION* Pupils, Visual Fields, Motility, External Exam can give lots of important information even if you can never get a view of the fundus.
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131	Tularosa Valley