Dr Sean EveryOphthalmologist

Southern Eye Specialists

Christchurch

8:30 - 9:25 WS #70: Eye Essentials for GPs

9:35 - 10:30 WS #80: Eye Essentials for GPs (Repeated)

Dr Jo-Anne PonOphthalmologist

Southern Eye Specialists,

Christchurch Hospital, Christchurch

How to usefully examine an

eye in General Practice

Sean Every

Ophthalmologist

Cataract and Vitreo-Retinal Surgeon

The problem

~2% of consultations in General Practice are eye related

Variable experience - some GP’s “scared stiff of eyes”

Commonly no slit lamp to examine the eye

Busy clinics

Variable distance to the nearest optometrist, hospital or ophthalmologist

Don’t underestimate yourselves

Pay careful attention to the symptoms reported

given the difficulty of accurately evaluating the

signs

Examination starts with history

Pain

Photophobia

Blurred vision (can they blink it away?)

Double vision

Trauma (mechanism of trauma)

History

Ocular

Myopia

Inflammatory eye disease

Eye operations – surgery, laser

Eye drops

Medical

Cardiovascular risk factors

Diabetes

Family ocular history

Glaucoma

Macular degeneration

Squints/amblyopia

Tools in the tool box

Hardware

Snellen chart

Pinhole

Ophthalmoscope

+/- penlight

Visual targets

Red

Interesting toy which a child will look

at

Pharmaceuticals

Topical local anaesthetic

Fluorescein stain

Dilating drops

Gutt Tropicamide 1%

Topical local anaesthetic

Might be the first useful thing you can

do

Aid diagnosis

localises pathology to ocular surface

Analgesia

Allow accurate VA test

Allow examination

Snellen Acuity The single most useful summary of eye

anatomy/physiology/optics and function

1. Well illuminated chart at the

correct distance

1. Make sure they haven’t put

reading glasses on

“are these the glasses you use for

distance or driving”

3. Effective occlusion other eye

• Palm of the hand

• NOT fingers

What does a Snellen VA mean??

The top number is the test distance in metres

The bottom number is taken from the lowest line read on the chart

A pseudo-fraction which measures the size of detail they can resolve

6/60 is 10X the size of the 6/6

6/24 is 2X the size of the 6/12

Can’t read the top line?

Action

Reduce the distance between patient

and chart

6m reduce to 3m, 1m

Count fingers

Perception light

Projects accurately

No projection

No perception of light

Notation

— 3/60 1/60

— 1/CF

— PL

— NPL

The pinhole acts like a universal

spectacle lens by reducing the blur on the retina

refractive error improves with pinhole

Refer optometry for glasses

other eye pathology does not improve

with pinhole

Refer ophthalmology

“I left my glasses in the car Dr” – use

a pinhole

Near Acuity: bedside in the rest home

Search Near Vision Test on your phone

Testing acuity in kids

- a skill which requires training and practice

0-3 years

Corneal reflex

Red reflex

Fix and follow a target

4-6

Identify 6/12 line each eye (not

binocularly)

Some 4 yr olds won’t cope

7+

6/9 or better

Ophthalmoscope

Red reflex

Corneal reflexes (testing alignment)

Magnifying lens (to look at skin lesions

or the anterior segment)

Cobalt blue filters to look for

fluorescein staining

Funduscopy

Start at zero

Alignment: corneal light reflexes- Kids: “my childs’ eyes aren’t straight”

- Adults: “I’m seeing double”

Normal

Squint

convergent divergent

Pseudo esotropia

Pupils: red reflex

Media opacities

Symmetry

Colour

Brightness

Tips

Dim room

Can use parents reflex as a baseline

External eye examination

symmetry

Lids

Sclera show

Remember a significant portion of

ocular surface under the lids

Orbit

Unilateral red eye

symmetry

Right ptosis

Left proptosis

Left upper lid

retraction

Right unilateral red eye

Motility….- don’t get bogged down

- forget about the cover test

- history trumps everything even if examination seems normal

Sixth Cranial nerve

Lateral Rectus

Horizontal diplopia

Fourth Cranial nerve

Superior Oblique

Vertical/torsional Diplopia

Third Cranial Nerve

Vertical

Horizontal

Ptosis

Pupil dilated

PEARL control fixation to neutralize the near reflex

Equal

Iris stuck

Autonomic Innervation

3rd CN palsy

Horner’s

Anticholinergic blockade

gardening

oven cleaners

nebulized asthma drugs

Reactive to light

Individually

Relative

Relative afferent pupillary defectcompare retina/optic nerve function between the eyes

RAPD

Objective

Swinging flashlight test

Pupil dilates on affected

side with light stimulus

A great test but difficult to

do well and hard to detect

in subtle disease

Look it up on youtube….

Brightness Sensitivity

Subjective

Easy to do

“is the light the same

brightness in each eye”

Visual Fields (VF)

Is a test of

retina

optic nerve

visual pathway

visual cortex

VF defects can be

Absolute

Relative

Test strategy to detect relative VF defect

Control patient fixation

Lots of reminding and prompting

Test strategy depends on patient

Left Right

VF test optionsfor visual field defects respecting the vertical midline

1. “look at my nose”

“keep your eye still”

“can you see all of my face with

the edge of your vision”

“which part is missing”

2. Simultaneous finger counting

3. Red desaturation across the

vertical midline

Anterior segment of the eyeanterior to the iris

Direct unaided observation

Use the magnifying lenses in the

ophthalmoscope

Cornea should be clear

Fluorescein staining

Use strips rather than drops

Drops pool in the tear film and so

much fluroescein present that can’t

see any corneal staining

Funduscopy

Don’t be afraid to dilate if clinical

scenario justifies

Risk of precipitating acute glaucoma

incredibly low

No one will blame you!

Possibly done them a favour

At risk if their distance glasses are

like high powered magnifiers

Good for optic disc and macula

High magnification

Small field of view