Basic Clinical Skills in Ophthalmology
Remember
Ophthalmology does not end at the back of the eyeball
It involves the whole visual system back to the visual cortex
Many systemic diseases have ocular complications
These patients may initially present to the ophthalmologist
The commonest cause for being registered partially sighted or blind under the age of 65
years is diabetes mellitus
HISTORY
Common symptoms
“The red eye” (pain, redness, photophobia, discharge)
= front of eye
Painless loss of vision
= back of eye
Misty vision/glare
= cataract
Distortion of vision/central scotoma
= macula
Flashes and floaters
= vitreous/retina
EXAMINATION
Visual acuity
The ability of the eye to see detail
Distance acuity
1
each eye is tested separately using a Snellen chart
tested at a distance of 6m - normal 6/6 (in USA is 20/20 as feet used)
Near acuity
both eyes tested together
at a distance of 33cm - normal N5
Visual acuity
Snellen comprises rows of letters of decreasing size labelled 60 (top letter), 36, 24, 18, 12,
9, 6, 5
Normal distance acuity i.e. 6/6 means that the row of letters with the number 6
underneath can be read at a distance of 6m
Visual acuity
numerator = distance away from the chart in metres
denominator = the number underneath that row of letters seen
if cannot see the top letter at 6 metres
then test nearer the chart (5, 4, 3, 2, 1m)
Visual acuity
lower levels of visual acuity are
counting fingers (CF)
hand movements (HM)
perception of light (PL)
no perception of light (NPL, stone blind)
if visual acuity is not at least 6/9 then use the pinhole test
2
Refractive error
Emmetropia
Myopia
Hypermetropia
Astigmatism
Emmetropia
There is no refractive error and light rays from infinity are brought to a focus on the
retina
Myopia (short-sighted)
Light rays from infinity are brought to a focus in front of the retina:
the eye is too long - axial myopia
or
(the lens is too “strong” from nuclear sclerotic cataract - index myopia)
Hypermetropia (long-sighted)
3
Light rays from infinity are brought to a focus behind the retina - the eye is too
short
or
(the converging power of the cornea or lens is too weak)
Astigmatism
The cornea is not spherical - rugby ball shaped rather than football shaped
Accommodation
Physiological mechanism that allows close objects to be focused on the retina
In the non-accommodative state the circular ciliary muscle is relaxed - allowing the
suspensory ligaments of the lens to remain taut
Accommodation
Physiological mechanism that allows close objects to be focused on the retina
In the non-accommodative state the circular ciliary muscle is relaxed - allowing the
suspensory ligaments of the lens to remain taut
4
Accommodation
During accommodation the ciliary muscle contracts and the suspensory ligaments
become lax causing the naturally elastic lens to assume a more globular (convex)
shape
Accommodation
With age (usually >45 years) the lens gradually hardens and is unable accommodate
- presbyopia
Accommodation
This can be corrected by a weak converging (plus) convex lens
RAPD
Relative afferent pupillary defect
Slit lamp microscope
5
Front of eye
Just look
Fluorescein + blue light
Cataract Surgery
Phakoemulsification and posterior chamber intraocular lens (IOL) implant
mainly LA (day case) or GA
small incision ~ 4 mm
removal of anterior lens capsule
high speed vibrating tip cuts nucleus into tiny particles and aspirates them
Phakoemulsification and posterior chamber intraocular lens (IOL) implant
irrigation and aspiration of remaining cortex
retains posterior capsule
insertion of foldable (e.g. silicone/acrylic) posterior chamber IOL into capsular bag
no sutures - reduced astigmatism
fast healing and visual rehabilitation
Intra-ocular lens
6
Intra-ocular pressure (IOP)
maintained at 10-21 mm Hg
dynamic balance between secretion and drainage of aqueous humour
high IOP (glaucoma)
leads to loss of visual field and eventual blindness
OPHTHALMOSCOPY
Back of eye
Direct ophthalmoscopy:
What are you trying to achieve?
How do you do it?
What are you trying to achieve?
To see the fundus
Optic disc
Retina
Macula
Blood vessels
Also
Media opacities
Cornea
Lens
Vitreous
7
Ophthalmoscopy for dummies
What is an ophthalmoscope?
How do I
Hold it?
Know what settings to put it on?
Know where to look?
Know what I’m looking at?
What is an ophthalmoscope?
Instrument with three essential components
Lenses
Light
Diaphragm
The direct ophthalmoscope
Magnification approx. 15 x
Field of view 6.5 - 10 degrees
With an undilated pupil
You will not see the macula
The disc will take up the whole field of view
Don’t ask the patient to look into your light as the patient will accommodate and
together with the bright light from your ophthalmoscope will make the pupil even
smaller
8
What lens should I set it on?
Do you wear glasses? - If so, keep them on
Set the ophthalmoscope to zero
THEN
Adjust the lens according to the patient’s refractive error
What lens should I set it on?
Ask the patient if they wear glasses
If only for reading then do not adjust the lens further
If for the distance (driving, TV) then ask if they are short sighted or long sighted
BUT
Many patients get confused and may give you the wrong answer
What lens should I set it on?
Pick up the patient’s glasses and hold them about 4 inches from you
With one eye look through one lens at a distant object
If the object appears smaller then they are myopic
If the object appears larger then they are hypermetropic
What lens should I set it on?
The smaller the object and thicker the lens the higher the degree of myopia and the
higher the lens number (red) on the ophthalmoscope
The larger the object and thicker the lens the higher the degree of hypermetropia and the
higher the lens number (black) on the ophthalmoscope
9
Direct Ophthalmoscopy
Ophthalmoscope with bright light - halogen bulb if possible, bulb not broken, recharged or
new (ish) batteries
Your right eye for the patient’s right eye
Your left eye for the patient’s left eye
Patient sitting comfortably
Ask patient to fixate on distance object
Do not block vision to fellow eye
Semi-dark room, no bright lights or reflections
Direct Ophthalmoscopy
Do not put your hands on the top of a patient's head
Women and many men would not like you to mess up their hair
You cannot do much about your patient's breath or personal hygiene, but you can yours
so make sure to pay some attention to both
Direct ophthalmoscopy
Remove the patient’s glasses (if they are wearing any)
Hold ophthalmoscope with your index finger on the lens dial
Set ophthalmoscope lens to see fundus
Approach from an angle of about 15 degrees temporal to the patient
You must be at the same height as the patient
Direct Ophthalmoscopy
Start with your dominant eye
Close your non-dominant eye (with more experience you will be able to keep both eyes
open)
10
Use the diaphragm dial to set the small white beam for an undilated pupil and large white
beam for a dilated pupil
Shine the light at the pupil and observe the red reflex (yellow/orange glow)
The greater the refractive difference between you and the patient the more blurred will
be the red reflex
Direct Ophthalmoscopy
Aim about 15 degrees nasal and get nearer to the patient keeping the red reflex as your
guide
This is where the optic disc is and it should not be uncomfortable for the patient as it is
their blind spot
About a few inches from the patient the fundus should come into view
What should I look at?
Optic disc (think of the 3 Cs: cup, colour and contour)
Colour
Cup:disc ratio
Contour (margins)
New vessels (if diabetic)
Retinal blood vessels
Arterioles and veins
Calibre
New vessels, collateral vessels
Tip: If you cannot see the disc follow the blood vessels towards their apex
11
What should I look at?
Macula (if pupil dilated)
Foveal reflex
Haemorrhages
Microaneurysms
Exudates
Cotton wool spots
Drusen
Atrophy
What should I look at?
Elsewhere
Haemorrhages
Microaneurysms
Exudates
Cotton wool spots
New vessels
12
