Ophthalmology protocols clinical examination



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OPHTHALMOLOGY PROTOCOLS

CLINICAL EXAMINATION



Visual Acuity:

Tools required: Snellen chart, trial frame, occluder, pin hole, Jaegers chart,paper and pen for documentation

1.seat the patient at a distance of 6 meters from snellen chart

2.explain that he/she has to use each eye turn by turn while the other eye is covered and read the alphabets or show with his/her hand the direction of the letters pointed by the examiner

3. make him/her wear the trial frame

4.occlude one eye preferrably right eye

5.point to each letter in descending line and ask him/her to say aloud or point the direction with hand

6.if the patient is unable to see the top most letter then reduce the patient distance from snellen chart by asking the patient to move forward so that he/she is at 5 meters now

7. keep on reducing the distance at 1meter intervals until patient is able to read the top most letter

8. if the top letter is not seen even at 1 meter then ask him/her to count the shown fingers as two or five fingers

9. if still unable to resolve then move your hand vertically or horizontally at a distance of 2 feet.

10. if still no positive documentation then shine light in front of his/her eye from distance of I foot and document as perception of light

11.if light is perceived from straight ahead, move the ligth sequentially into each of the four quadrants of visual field. Turn the penlight on and off in each field and ask if the patient can appreciate the direction from which the light is coming.

12. cover or occlude the left eye now and reapeat steps 5-11.

Documentation:

Right VA Left or VA 6/24

6/24 6/60 6/60

If the patient is missing some letters in a line then document as

Right VA Left or VA 6/24-2

6/24-2 6/60 6/60

Pin hole Visual Acuity

If a patient vision is less than ideal then its checked with pin hole to exaclude any refractive error

1.seat the patient at a distance of 6 meters from snellen chart

2.explain that he/she has to peep through a small hole in front of one eye while the other eye is covered.

3. make him/her wear the trial frame

4.occlude one eye preferrably left eye

5.put pin hole in front of the better eye or right eye

6. ask him to read or point in the direction of the shown letters.

7.document your findings as

Right VA with pin hole Left or VA with pin hole 6/9

6/6 6/18 6/18

Visual Acuity with glasses

1.seat the patient at a distance of 6 meters from snellen chart

2. ask the patient to wear his/her present glasses

2.explain that he/she has to cover left eye with a card and read or point the direction as he/ she has done before.

3.cover left eye with a card and ask him to read or point in the direction of the shown letters.

4.document your findings as

Right VA with glasses Left or VA with glasses 6/9

6/6 6/18 6/18



Near Visual Acuity

  1. Make the patient sit comfortably in a well illuminated room

  2. Ask him/her to hold the Jaegers chart at a comfortable distance and read the sentence or point the direction of the letters

  3. If the patient is using glasses, check the readings with glasses

  4. Document your findings as

Near VA N8 both eyes

Frequently asked questions:

1.Define and classify ametropia.

2. define myopia. Describe the treatment modalities.

3.Define hypermetropia. Which lenses are used to correct it

4. define astigmatism. How can you correct it

5. define presbyopia.

6. what is a Retinoscope. Discuss its principle.

7. what is an autorefractometer.

8. Describe the principle of Pin Hole

9. how can you identify a lens as a concave or convex lens

10. how can you identify a lens as a spherical or astigmatic lens

PUPIL EXAMINATION

Tools required: Torch light, distant fixation target, near fixation target


  1. Seat the patient comfortably

  2. Explain that patient has to look at a distant object e.g top most letter on snellen chart or a light switch on a switch board, while you are going to show some light into his/her eyes turn by turn to examin the black of eye

  3. Shine torch light below the eye to examin the pupil number,shape, site,size, colour and contour of pupil and iris.

  4. Dim the rrom lights. Shine torch light into right eye by approaching from side or from below and look for direct pupil reaction to light in right eye while indirect pupil reaction to light in left eye.

  5. Check the direct pupil reaction to light in left eye and indirect response in left eye by shining light in left eye

  6. Shine the light directly into right eye and then move it over the nasal bridge to shine in the left eye. Swing the light source quickly back to the right eye to check for the swinging light reaction

  7. Check for the near response of the pupil by asking the patient to look at the distant target

and then ask him/her to shift his gaze to a near target e.g. a thumb or a refraction or a visiting card

Documentation:

Pupils are equal in size, single,central, regular and black in colour

Direct and indirect pupil reactions to light are brisk in both eyes.

No relative afferent pupil defect

Pupil reaction to near is brisk.

Frequently asked questions:

1.Name the muscles of pupil

2.What is the nerve supply of pupil.

3.Describe the light pathway

4.Describe the near synkinesis

5.What is an afferent pupil defect

6.Define following terms:

Leukocoria

Anisocoria

Polycoria



EXTRAOCULAR MOVEMENTS EXAMINATION

1.Seat the patient comfortably

2. exlain to the patient that you want to check how his/her eyes can move in various directions so first he/she has to look staight and then has to follow the target in your hand e.g a pen or a toy for child.

3. ask patient to look at the distant target e.g snellen top letter

4. shine torch light at nasal bridge from 1 meter distance to look for corneal reflex in each eye to check for orthophoria

5.ask the patient to follow the target held in your right hand at a distance of ½ meter starting form the centre and moving in a shape of letter H or *. Document the action of each muscle by this persuit movement

6.ask the patient to follow the target that is gradually approaching his/her eyes from a distance of one foot, look for the convergence or divergence

7. document that the patient is having orthophoria with good ocular movements in all dirction of gazes and normal convergence.

8. if you find any tropia, ask for to proceed with cover/ uncover test.

Right left

RSR LSR


LIO RIO


LLR

RMR




RLR

LMR

RIR LIR

LSO RSO


Frequently asked questions

  1. Name various extraocular muscles

  2. Describe the nerve supply of each muscle

  3. Define orthophoria

  4. Define and classify strabismus

  5. What are the steps in managing strabismus

  6. What is the importance of near synkinesis in managing starbismus

  7. Describe the importance of cover uncover test

DIRECT OPHTHALMOSCOPY

Tools Required: Direct ophthalmoscope, distant fixation target

  1. Seat the patient comfortably

  2. Explain that patient has to look at a distant object e.g top most letter on snellen chart or a light switch on a switch board, while you are going to show some light into his/her eyes turn by turn to examin the back of eye

  3. Shine light from direct ophthalmoscope into patients eye turn by turn from a distance of 2 feet to look for a fundal glow or red reflex.

  4. Hold direct ophthalmoscope in your right hand near your right eye and get closer to patient’s right eye at an almost 45 degree angle with patient looking straight ahead at a distant target.

  5. If pupil is dialted, follow the main vessel trunk and then bend your ophthalmoscope slightly temporally to focus at macula.

  6. Document your findings as

Red reflex is positive or fundal glow is red that signify that ocular media is clear.

Optic disc: colour contour and cup

Vessels: caliber and contour(wall thinning/thickening,local or diffuse constriction or dilatation)

Macula: normal with hyperpigmented fovea, absence of any hemmorhages, exudates, scar



Frequently asked questions :

  1. What is the significance of red fundal glow

  2. Which eye drops are used in eye outpatient for pupil dilatation

  3. How does the normal disc look like.

  4. Name a few pathologies seen in fundus.

  5. Name the systemic diseases that can bring changes in fundus





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