CASE PRSENTATION

OPHTHALMOLOGY Department

Dr. Jyotsna Pandey

 HISTORY
NAME :
AGE :
SEX :
RELIGION :
OCCUPATION :
MARITIAL STAUS :
ADDRESS :
DATE OF EXAMINATION:
 CHIEF COMPLAINS
1.
2.
3.

- Symptoms?
- Which eye affected?
- Duration?
 HISTORY OF PRESENT ILLNESS
• According to the patient she was apparently well ___ days back when she
developed …………………….

• Ask history of redness, discharge, blurring of vision, foreign body

sensation, headache, ocular pain, headache, glaring, double vision or
colored haloes

• Symptoms: Onset, duration, associated symptoms?

PAST HISTORY
• Ask history of ocular trauma or ocular surgeries in the past: When and which eye?
• Ask history of use of glasses or contact lens in the past: Duration? Last glasses
changed?
• Any treatment done for the above case before visiting the hospital?
• Similar illness in the past

MEDICAL HISTORY:
History of hypertension, diabetes, thyroid disorder, asthma, heart disease

PERSONAL HISTORY:
• Appetite
• Diet: Non vegetarian / veg diet
• Bowel and bladder habit
• Non smoker, non alcoholic
MENSTRUAL HISTORY
Incase of female

DRUG AND ALLERYGY HISTORY

History of any allergy to pollen, drugs or food

FAMILY HISTORY
History of similar illness in her family
History of hypertension, diabetes mellitus or thyroid disorder

SOCIOECONOMIC HISTORY:
No. of members in the family
Kanchi/ pakkhi house and facility of water and sanitation
SYMPTOMS
1. Blurring of Vision: Near/ distance, Day/ Night more, Painful / painless?
2. Redness: Painful / painless? Associated with discharge?
3. Discharge: Types of discharge?
Swelling of eyes
4. Watering
Mass in the eye
5. Itching Distorted Vision
6. Foreign body sensation Deviation of eyes
Protrusion of eyes
7. Ocular Pain Diminished field of vision
8. Headache: Site?
9. Glare: Is there any difficulty seeing in bright light?
10. Photophobia: Is there any difficulty to see/open eyes in normal intensity light?
11. Floaters: Is there any black spots in front of the eyes?
12. Photopsia: Is there any flashes of light in front of eye?
13. Colored Haloes: Are you perceiving colored rings around lights? (or rainbow haloes)
GRADUAL PAINLESS DIMINUTION GRADUAL PAINFUL
OF VISION DIMINUTION OF VISION
• Refractive errors • Corneal ulcer
• Progressive pterygium encroaching • Chronic iridocyclitis
pupillary area
• Corneal degenerations and
dystrophies
• Cataract
• Primary open-angle glaucoma
• Macular degenerations and
dystrophies
• Diabetic retinopathy
• Hereditary optic atrophies
• Drug-induced optic
• Amblyopia
SUDDEN PAINFUL DIMINUTION SUDDEN PAINLESS DIMINUTION
OF VISION OF VISION
• Mechanical or chemical trauma • CRAO, CRVO, BRAO, BRVO
• Acute iridocyclitis • Retinal detachment
• Acute angle-closure glaucoma • Vitreous hemorrhage
• Endophthalmitis • Optic Neuritis
• Cystoids macular oedema
• Central serous retinopathy
• Acute ischemic optic neuropathy
(AION)
NIGHT BLINDNESS: FLOATERS:
• Vitamin A deficiency • Posterior vitreous detachment
• Retinitis pigmentosa • Vitreous hemorrhage
• Congenital stationary night blindness, • Vitreous opacities
• Pathological myopia • Pars planitis

DIMINUTION OF NEAR VISION: PHOTOPSIA (d/t traction on the

vitreoretinal
• Presbyopia attachments irritating the retina and
• Installation of Tropicamide, Atropine causing it to discharge electrical impulses)

• Ophthalmoplegia • Posterior vitreous detachment

• Retinal tear
• Retinal detachment
GLARE: PHOTOPHOBIA:
(D/t diffraction of light caused by opacities in the cornea D/t stimulation of sensory nerve endings of cornea
and lens) • Corneal Ulcer
• Immature cataract
• Corneal epithelial defect
• Corneal opacities
• Acute iridocyclitis
• Large pupil
• Use of mydriatic and cycloplegic
• Chemical burn

COLORED HALOS
D/t prismatic dispersion of light (breakage of light into WATERING
seven colors because of abnormal collection of fluid) in
cornea or lens • Hyperlacrimation due to either central
lacrimation or primary hypersecretion or reflex
• Acute mucopurulent conjunctivitis hyperlacrimation
• Corneal edema because of bullous • Epiphora due to obstruction in the lacrimal
keratopathy or acute congestive drainage system
glaucoma
• Immature cataract
DIPLOPIA
UNIOCULAR BINOCULAR
If diplopia disappears by obstructing the affected eye If diplopia disappears by closing one of the eyes
• Keratoconus • Paralytic squint
• Double pupil : Iridodialysis • Myasthenia gravis
• Subluxated lens • Fractures of orbit with
• Displaced intraocular lens entrapment of extraocular
• Incipient cataract muscles
• High astigmatism • Thyroid ophthalmopathy.
REDNESS
PAINFUL PAINLESS
• Trauma • Inflamed Pterygium and pingecula
• Acute iridocyclitis • Conjunctivitis (Bacterial, Viral,
• Corneal ulcer Allergic)
• Herpes zoster • Blepharitis
• Foreign body • Dry eye
• Acute congestive glaucoma • Subconjunctival Hemorrhage
• Scleritis • Episcleritis
• Endophthalmitis
QUESTIONS
1. Difference between conjunctival and circumcorneal congestion.
2. Difference between bacterial, viral and allergic conjunctivitis.
3. Difference between Acute Conjunctivitis, Acute Iridocyclitis and
Acute Congestive Glaucoma
4. Difference between bacterial and fungal corneal ulcer
5. What is follicles, papillae and concretion?
6. Write down causes of Subconjunctival Hemorrhage.
PHYSICAL EXAMINATION:
• General Physical Examination:
• Built
• Weight
• Orientation to time, place and person

Pallor, icterus, cyanosis, clubbing, edema

Lymph nodes palpable / not
Hydration status: normal

• Vitals:
• Pulse Rate
• Blood Pressure
• Respiration Rate
• Temperature
15
SYSTEMIC EXAMINATION
OPHTHALMOLOGICAL EXAMINATION
1. VISUAL ACUITY (Unaided): Questions:
PH
- What is visual acuity?
Eg: VA RE: 6/9 6/6
Glasses
6/6 - Mechanism of pinhole.
Glasses - Charts used to measure distant
LE: 6/9 6/6
PH
6/6 and near visual acuity.
- Snellen's chart interpretation
Near Visual Acuity: - Numbering in the Snellen’s
chart
Eg: NVA RE: N6 at 25 cm - Eg: What do you mean by VA
6/60?
LE: N6 at 25 cm - Why VA is taken at 6m
distance?
- Procedure
- Causes of painful, painless,
gradual and sudden diminution of
vision
 VA Procedure:
• The patient is asked to read the chart
• Visual acuity is defined as the ability to separately in each eye after closing one eye
distinguish the shape of objects from top to bottom.
• Numbering: 60, 36, 24, 18, 12, 9, 6
• If the patient is not able to read the top
• "Visual acuity 6/60" means that a person can
only see at a distance of 6 meters what a most line from 6 m he/she is asked to move
person with normal vision can see at 60 by 1 m front till he/she can see the top most
meters away line clearly, then numerator becomes 5/60,
• At 6m distance, the rays are nearly parallel, 4/60, 3/60, 2/60, 1/60
and the patient usually does not • If the patient cannot read from 1 m then
accommodate to see at this distance.- so VA is
taken at 6m / 20ft distance. check for:
a. Counting fingers at 2/3rd and ½ m.
• Distant Vision Charts: Snellen’s letter b. Counting fingers close to face. (CFCF)
chart ,Snellen’s E chart, Landolt’s C chart,
Allen’s picture chart. c. Hand movements(HM)
• Near Vision Charts: Jaeger chart, Roman near d. Perception of light with projection of rays in
vision chart, Snellen’s near vision chart all the four quadrants. (PL with PR)
e. No perception of light (NPL)
2. GROSS EXTERNAL EXAMINATION:
• No visible swelling
• No abnormalities seen in forehead, eyebrow, eyelashes and face
• No scar marks, ecchymosis, bulging of eye or shrunken eye

3. HEAD POSTURE: Straight without any head tilt or turn of the face or elevation/
depression of chin.

Head Tilt: SO palsy

Face turn: LR and MR palsy
Chin up: Ptosis, Paralysis of elevators (SR and IO) , Overaction of depressors
(IR, SO)
Chin down: Paralysis of depressors of eyeball, Overaction of elevators.
4. EXTRAOCULAR MUSCLE MOVEMENT

Uniocular: Full range with no pain Binocular: On version- full ranged with no pain
and restriction of the movement and restriction of movement on dextroversion,
dextroelevation, dextrodepression, levoversion,
on adduction, abduction, elevation levoelevation and levodepression
and depression Questions:
- Each muscle origin, insertion and
OD OS BE actions
- Name the yolk muscles
- Convergence Test adequate at what
distance?- 8 to 10cm
- How to examine?
- Use pen tip or torch
- Ask pt. not to move head and
follow the object with eyes only
- Uniocular: Cover one eye while
testing the other
- Binocular: Make H

Components of Near
CONVERGENCE TEST: Adequate Reflex?
- Convergence Test:
- Bring Pen tip from distance
- Ask pt. to raise his hand when he will experience blurring of vision/ double vision.
- Measure the distance from tip of nose to tip of pen.
 5. HIRSCHBERG’S TEST (IN BOTH NEAR AND DISTANCE):
Light reflex seen symmetrically in center of each eye

6. COVER TESTS: ( FOR BOTH NEAR AND DISTANCE) (33cm and 6m fixation distance)
• Direct Cover Test: No corrective eye movement seen in both eyes
• Cover Uncover Test: No corrective eye movement seen in both eyes
• Alternate Cover Test: No corrective eye movement seen in both eyes
Questions:
- Degree in Hirschberg’s Test
- No Squint: Orthophoria
- Direct Cover Test: Detect tropia/ manifest squint – cover fixating eye and see movement of deviated eye- it will take fixation
(Inward movement: Exotropia, Outward movement – Esotropia)
- Cover Uncover Test: Detect phoria / latent squint – One eye is covered which break the fusion, the eye under cover deviates
(Inward refixation movement: Exophoria and outward refixation movement: Esophoria)
- Alternate Cover Test: Both tropia and phoria- Total deviation - Here eye is covered for more than 2 seconds and
the cover is immediately shifted to other eye while observing the movement of the covered eye, this is
repeated several times. The principle is to break fusion and to make the latent squint to manifest,
7. PALPEBRAL FISSURE HEIGHT:
OD OS

VERTICAL HEIGHT

PRIMARY POSITION 10 mm 10 mm

LOOKING UP 12 mm 12 mm

LOOKING DOWN 3 mm 3 mm

LEVATOR PALPEBRIS 16 mm 16mm

SUPERIOSIS FUNCTION

HORIZONTAL LENGTH 30mm 30mm

MRD1 4mm 4mm

MRD2 5mm 5mm
8. EYELID AND ADNEXAE:
• Upper eyelid covers 2mm of the cornea while the lower eyelid just
touches the limbus on both eyes
• There is no swelling, ecchymosis, abscess, nodule, naevus, scaring,
ulceration on both eyes
• Eyelid crease present 8 mm above the lid margin of both the eye
• Patient can voluntarily open and close the eyelid of both eyes
• Blinking reflex is 12 times/min in BE (Normal: 12-16 times/min)
9. Eyelid Margin:
• Upper eyelashes directed downward, forward and upward
and lower eyelashes are directed upward, forward and Questions:
downward in both eyes - Difference
• No redness, swelling, abscess, naevus, scales, scaring, between stye and
ulceration. chalazion

• No loss of eyelashes and inward turning of lashes

• Opening of meibomian gland was not prominent
Regurgitation Test (ROPLAS -
Regurgitation on
10. Lacrimal Apparatus: pressure over lacrimal
• No swelling in upper and lateral part of eyelid of both eyes. sac): On pressure to the
medial aspect at the base of
• Both upper and lower punctum touches eyeball and open the nose just below and
in both eyes medial to the medial
• Examination of medial aspect at the root of the nose : No canthus: no regurgitation of
any localized swelling, redness, fistula any discharge

• Regurgitation test was negative

 Questions:
- What is follicles and
11. Conjunctiva: papillae and
conditions where
• On bulbar conjunctive there is no congestion, discharge, theses are present.
- Difference between
chemosis, cyst, foreign body, pigmentation, scar, pterygium or
bacterial, viral and
pingecula allergic conjunctivitis.
- Difference between
• No congestion, discharge, follicles, papillae, concretion, foreign pterygium and
body present in tarsal conjunctiva of both eyes on everting pingecula
- How do you evert
upper eyelid
12. Cornea and Sclera:
Questions:
• Transparent in both eyes with good corneal luster - Uses of fluorescence
• No oedema, foreign bodies, vascularization, opacity on both strip?
- How do you check
eyes corneal sensation?
- Afferent and efferent of
• Corneal sensation: Intact corneal reflex?
• No congestion or discoloration in the sclera - Conditions where
corneal sensation is
decreased?
• Follicles are aggregation of lymphocytes, which present as elevated
lesions with pale centers, seen in follicular conjunctivitis (Viral
conjunctivitis, Toxins), trachoma.
• Papillae represent blood vessels surrounded by inflammatory cells,
which present as flat lesions with hyperemic center, seen in allergic
conjunctivitis.
• Add treatment
• Add investigations in detail and also treatment option
13. Anterior Chamber: Aqueous cells and
flares are usually
• Iris Shadow Test seen in AC only in slit
lamp examination
• No visible pus or blood in AC of both eyes
- How do you do the iris shadow
test?
- Causes for hypopyon and hyphema
14. Iris: with its treatment?
- Causes of deep and shallow AC?
• Brown in color
- What is
• Pupillary margin is smooth, collarette present Heterochromia?
- Conditions
• No blood vessel in the surface of iris, no pigmentation, seen?
nodules, mass, atrophy, abnormal holes in both eyes, - Iridectomy /
Iridotomy is
done in which
site and why
usually?
 RRR: Round, regular and reactive
15. Pupil:

Right Eye Left Eye - What are the

Size (Approximately) 3mm 3mm physiological,
pharmacological and
Shape Round Round
pathological causes
Regularity Regular Regular for miosis and
Symmetry Symmetrical B/E mydriasis?
- What is RAPD?
Direct Light Reflex Brisk Brisk How do you
Consensual Light Brisk and equal Brisk and equal check it? Causes
Reflex for RAPD
Swinging Light Reflex Brisk and equal Brisk and equal - Reason behind
the consensual
reflex?
16. Lens:
• Centrally located and transparent in both eyes
• No opacity, dislocation or subluxation

17. Fundus Examination: (After dilatation with Gtt tropicamide): Not required in the
examination part
OD OS
MEDIA Clear Clear
OPTIC DISC
CUP DISC RATIO 0.2:1 0.2:1
Margins are well defined Margins are well defined

COLOR Pink in color Pink in color

MACULA Good foveal reflex Good foveal reflex
BLOOD VESSELS 2:3 2:3
AV RATIO
No hemorrhage, neovascularization, exudates
18. DIGITAL TONOMETRY:
- Firm on both eyes

When the index finger kept at the medial aspect of eyelid is fixed whereas
the fluctuation is felt with the index finger kept in the lateral side, Fluctuation
felt was firm suggestive of normal IOP

- Conditions of increased
Normal: Firm IOP and decreased IOP?
- Instruments to measure
Increased IOP: Hard
IOP?
Decreased IOP: Soft
OTHER SYSTEMIC EXAMINATION

• Cardio vascular System: S1 S2 M0

• Respiratory System: Bilateral vesicular breath sound with no added

sound

• Abdomen: Soft and Non-tender, no mass

• CNS: Intact
PROVISIONAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS: Write the point favoring and against the provisional
diagnosis

SUMMARY
OCULAR EXAMINATION
1. Perform Visual Acuity Test
2. Extraocular Examination
3. Convergence Test
4. Near Reflex
5. Pupillary Light Reflex
6. Cover Uncover Test
7. Hirschberg’s Test
8. Convergence Test
9. Digital Tonometry
10. Corneal Sensation
11. AC depth
12. Regurgitation Test
13. Examine Eyelid, Conjunctival and Cornea
THANK YOU