Eyes diplopia

							                                                  Eyes
HPI
   -   Eyelids: ptosis
   -   vision disturbances: one or both eyes, corrective lenses, central/peripheral vision, transient or
       sustained, cataracts, color vision, halos, floaters, diplopia
   -   pain: in or around eye, onset, characteristics
   -   secretions: color, consistency, duration, tears, conjunctival redness
   -   medications: eye drops, ointments, abx, …
PMHx
   - trauma
   - eye surgery
   - illnesses that may effect vision (HTN, DM, collagen vascular dz, IBD, glaucoma, allergies)
FMHx
   - retinoblastoma or cancer of retina
   - condition similar to patient’s
   - color blindness, cataracts, DM, glaucoma, retinitis pigmentosa, macular degeneration, allergies
   - nearsightedness, farsightedness, strabismus, amblyopia
SHx
   - occupation: exposure to chemicals, foreign bodies, …
   - activities that might endanger the eyes
   - corrective lenses (contacts or glasses)
Physical Exam
   - visual testing
           o visual acuity – tests CN II
                   use Snellen chart and have patient stand 20ft away
                   test each eye while covering the other
                   record as a fraction: the numerator is the distance they are standing from the
                      chart (20), and the denominator is the number on the last line the patient wa able
                      to read.
                           Ex: 20/200 means what the patient could read at 20ft, the average person
                               can read the same thing at 200ft (20/200 = legally blind)
           o peripheral vision
                   confrontation test: cover your right eye and patient covers his/her left eye and
                      look at each other. Extend arm and wiggle fingers while moving arm centrally.
                      Test nasal, temporal, superior, and inferior fields.
   - external examination
           o eyebrows: size, extension, texture
           o orbit: edema, puffiness, sagging tissue
           o eyelids: wrap t
                   fasciculations, tremors, flaky, red,
                      swelling
                                                                                       QuickTime™ and a
                   ptosis: if superior eyelid covers                         TIFF (Uncompressed) decompressor
                                                                                 are needed to see this picture.

                      more of the iris than the other eye
                      and covers the pupil when the eye
                      is open
                   ectropion – everted lower eyelid 
                      excessive tearing
                   entropion – eyelid turned inward.
                      Eyelashes may cause corneal and
                      conjunctival irritation and increase risk of infection
                     sty (hordeolum): red or yellow lump, blepharitis (crusting on eyelashes)
   -   Palpation
           o palpate eyelids for nodules
           o palpate eye for firmness and discomfort with gentle pushing
   - conjunctiva
           o lower lid: have patient look up while you draw lower lid downward
           o upper lid: evert lid with a cotton tip applicator (only do if suspect foreign body)
           o look for erythema, exudates, localized blood, growths
   - cornea
           o test clarity: shine light on it (should not see blood vessels since avascular)
           o test sensitivity: touch with cotton wisp (sensory via CN V = trigeminal) and patient
               should blink (motor response via CN VII = facial)
   - iris and pupil:
           o note shape, symmetry, and size (should be the same in both eyes)
           o test pupil response to light directly and consensual
           o test pupil accommodation: have patient look at distant object and then at object (finger)
               10cm from the bridge of his/her nose
   - lens
           o should be clear
   - sclera
           o should be white (yellow or green in liver dz)
   - lacrimal apparatus
           o inspect lacrimal gland region and palpate lower orbital rim near inner canthus
Extraocular muscles
   - have patient look straight ahead, have them follow your finger with their eyes through the 6
       fields of gaze
           o remember LR6SO4 and all others 3 – will go over in neuro section
   - nystagmus: involuntary rhythmic movements of eyes that occur in any direction
   - look for superior lid lag by having patient follow finger in vertical plane (ceiling  floor)
Ophthalmoscopic Exam
   - allows for visualization of optic disc, arteries, veins, and retina
   - difficult to do without dilating eyes (use meds, dimming lights may work)
   - examine patient’s right eye with your right eye, and patient’s left eye with your left eye
       otherwise you and/or your patient might get an unwanted kiss!
   - Hold ophthalmoscope with hand that corresponds to examining eye.
   - Put other hand on patient’s shoulder
   - Have patient look straight ahead
   - Direct light at pupil 1st 30cm away and visualize red reflex
       and move toward patient keeping the red reflex. As you
       approach the eye, retinal details should become apparent:
           o blood vessels                                                                QuickTime™ and a


           o optic disc (yellow or creamy pink and is 1.5cm in
                                                                                 TIFF (Uncompressed) decompressor
                                                                                    are need ed to see this picture.




               diameter, disc margins should be sharp and well
               defined)
           o macula (fovea centralis) = site of central vision.
               Located 2 disc diameters temporal to optic disc.
               No blood vessels enter the fovea and it appears as
               a yellow dot surrounded by a pink periphery (hard to see if eyes not dilated)