In the name of god

Clinical eye examinationHamid Fesharaki MD

Eye department Isfahan University of medical sciences

History & physical examination

Clinical eye examination History & physical examination

Clinical eye examination History & physical examination

Hand Held Acuity Card

Ophthalmic symptoms : pain, redness, itching, burning , F B sensation,

Visual loss

Snellen Chart

Physical examinationvisual acuity: fixation & follow, snellen chart

Clinical examination

Visual acuity: central, peripheralvisual acuity is hard to check due to its subjective nature: depends on the response of the patient (intelligence , previous experience, alertness)

Measurment of visual acuitymonocular vs binocular, wit or without correction

far and near

Accurate clinical eye examinationreduces the para clinical expensive testing Poor ophthalmoscopy may call for ocular sonography, OCT, FA…

Define the best corrected visual acuity firstRefraction is the beginning step of clinical examination clinical judgment without refraction can be miss guiding

RAPD (Retrobulbar neuritis)

Judgment by observation alone may be misleading A relatively pale optic disc Reduced light reflex of fovea Optometrist referral for retinal problem

Refractive error: retinoscopy, subjective refraction including the pin hole , autorefraction.

subjective refraction To find the best corrected visual acuity

Autorefrctor may give wrong numbers

Biomicroscopy

Direct ophthalmoscope

OPHTHALMOSCOPY

Direct ophthalmoscopy and

indirect ophthalmoscopy

through dilated pupil

inexpensive, rapid, efficient

Observation of the fundus structures is very important for clinical diagnosis.

Ophthalmoscopy

Retinal photography

Polaroid photographs

35mm colour slides

Digital images

- Scanner

- Video

- Digital camera

RETINAL EXAMINATION

OPHTHALMOSCOPY

Direct ophthalmoscopy and

indirect ophthalmoscopy

through dilated pupil

inexpensive, rapid, efficient

Visual loss:

1. Refractive error: retinoscopy, subjective refraction including the pin hole , autorefraction. (Irregular astigmatism)

2. Opacity of media: ophthalmoscopy, retinoscopy, biomicroscopy. (red reflex) 3. Retina & Optic nerve : ophthalmoscopic observation, RAPD, visual field,

ERG, EOG, VEP, angiography, OCT, ultrasonography.

(Amblyopia)

Amblyopia: history & phsical: Anisometropia, Isoametropia, Strabismic,

(Monofixation synd) 4 prism base out test

Malingering: age, gain, tricks

Legal writing

Beyond the optic nerve: RAPD,VEP, Visual field, brain imaging

Deprivation

Refractive error Irregular astigmatism

. Opacity of media: ophthalmoscopy, retinoscopy, biomicroscopy. ultrasonography

(red reflex)

Evaluation of retina & optic nerveVisual field: Confrontation, tangent screen

Visual field: Static & kinetic perimetry

Visual field: Static & kinetic perimetry

Evaluation of retina & optic nerve

• Observation: Compare between the two eyes, and compare with the population.

• Correlate between BCVA, clarity of visual pathway and fundascopic findings

• Relative afferent pupillary defect

• Function tests: visual field,VEP, ERG, EOG..

Retina & Optic nerve : Angiography, visual field, OCT, GDX, ERG, EOG, VEP, ultrasonography,

Beyond the optic nerve: Visual field brain imaging: MRI, CTscan

visual field

The pattern of visual field may be diagnostic

EYE EXAMINATION - ROUTINE

History

Visual acuity

Clinical examination of retina

Direct ophthalmoscopy

Indirect ophthalmoscopy

Retinal color photography

Fluorescein angiography

SPECIFICITY AND SENSITIVITY OF

OPHTHALMOSCOPY AND PHOTOGRAPHY

Ophthalmoscopy Photography

(%) (%)

Sensitivity 65.7 87.3

Specificity 93.8 84.8

Owens et al, Diabetic Medicine, 1998

GOLD STANDARD FOR RETINAL SCREENING

Seven 30 - degree field of stereoscopic

photographs taken by a trained technician

Photographs can be taken by a mobile

unit with a camera and later assessed by a

trained reader

Suited to serve even rural communities

Retinal photography is the gold standard for screening diabetic retinopathy

Snellen Chart For Acuity Testing

Checking Visual Fields By Confrontation

Left eye cannot move laterally

Observation External StructuresPupil, iris and eyelids & lashes should appear symmetric

Sclera should be whiteConjunctiva clear