ORIENTATION, HISTORY TAKING & EXAMINATION Dr. Yasser Al-Fakey M.D., M.Sc (Ophth.), FRCS Attendance and participation in Lectures & Tutorials Aiming to have solid knowledge wise and guiding you to work your way through the course. You should have a minimum of 75% attendance to be eligible to take the examination. Attendance in the Outpatient Clinics What are the common instruments and tools used in the clinic? How to use the instruments? What is the normal? Pay attention to the C/O and physical examination, then correlate them with the diagnosis. Ask, ask and ask the attending consultant; discuss with him the clue for the diagnosis and possible D.D. Respect the patient. Attendance in the OR You will be allowed to attend the OR to be familiar with the setup. Open discussion as regard common surgical procedures. Memories the indications, crucial steps and complications. Continuous assessment and Final Examinations OSCEs Multiple Choice Questions. HISTORY TAKING Two types of patients entering an ophthalmologist’s office: 1- Who desires routine ocular examination combined with refraction. 2- Patients with symptoms of ocular diseases. Organization of History Personal data. Chief complaint & its duration. History of present illness. History of past health. Medications. Allergies. Family history of ocular disorders. Personal Data Name. Age. Sex. Medical Rec.#. Marital Status. Residence. Occupation (type of work & industrial hazards). Special Habits ( smoker, alcoholic, drug addict …. etc.). Chief Complaint & its duration Headlines of any ophthalmic history. In a sentence or two, You should write down the main reason for which the patient has come for advice & help. How do your eyes trouble you? Specify date of onset, cause and duration. History of Present Illness Main symptoms with greater detail. When did the problem begin and under what conditions? Was the onset slow or rapid in development? Did it affect one or both eyes? Did he receive any medications? What aggravate it & what made it better? Course of symptoms. Visual Symptoms Blurred vision secondary to an error of refraction: 1- For close work. 2- For distance work. Blurred vision secondary to organic disease: 1- Loss of central vision. 2- Distorted vision. 3- Night blindness (Nyctalopia). 4- Visual field loss, ascending veil. 5- Transient gray -outs of vision. Blurred Vision due to media opacities: 1- Cornea (infiltrations, oedema & scar). 2- Anterior Chamber (inflammations, hge., infiltrations). 3- Lens (cataract). 4- Vitreous opacities. 5- Epiretinal membranes. Diplopia Double vision (two objects instead of one). Binocular (weak or paralyzed extraocular muscles) or Monocular (cataract, subluxated lens or extra pupil). Red Eye Unilateral or Bilateral. Onset, duration & course. Associated symptoms (discharge, Lymphadenopathy, blurred vision…etc) Differential Diagnosis: 1- Acute Conjunctivitis. 2- Acute iritis. 3- Acute angle closure glaucoma. 4- Corneal trauma or infections. Symptoms (cont.) Discharge (watery, mucopurulent, purulent and mucoid). Headache. Pain. Asthenopia. Floating spots and light flashes. Tearing. Abnormal appearance. History of Past Health Significant medical illness: Diabetes, Hypertension, Cardiac disorders and arthritis. Previous eye disorders (same eye or fellow eye). Contact lens. Previous surgery: Ophthalmic surgery. General surgery. Medications Any medications that the patient may be taking either systemic or topical. If he can’t identify the medications (common), you can ask the purpose of the medications. Antiglaucoma therapy. Hypoglycemic therapy. Other medications (for Preoperative assessment). Allergies Drugs (taken internally or applied topically). Inhalants (dust and pollens). Contactants (cosmetics and woolens). Ingestants (food allergies). Injectants (tetanus antiserum). Family History of Ocular Disorders In particular: Myopia, Strabismus, Glaucoma and Blindness. A negative family history does not rule out a genetic familial propensity (they do not know or reluctant to confess to any weak in their families). Others (migraine, keratoconus, retinitis pigmentosa, retinoblastoma….etc.). EXAMINATION Eye and systemic diseases: Ophthalmic diseases can be a manifestation of a systemic disease or reflected systemically. Human being has two eyes. So, if you missed one eye = ½ diagnosis & treatment. OD (oculus dexter) right eye. OS (oculus sinister) left eye. OU (oculus uterque) both eyes. Systematic examination. VISUAL FUNCTION Visual acuity: 1- Distance vision. 2- Near vision. Color vision. Visual field: 1- Kinetic perimetry (Confrontation method, Goldmann perimeter…etc.). 2- Static or automated perimetry. Visual Acuity (VA) It is a measure of the ability to discriminate two stimuli separated in the space. The normal eye can distinguish two points separated by an angle of 1 minute to the eye. 20 feet or 6 meters (20/20 or 6/6). Numerator = distance from the chart. Denominator = person with normal vision. Pinhole effect. EXTERNAL INSPECTION Symmetry of the orbits, lid margins, conjunctiva, lacrimal apparatus, sclera, cornea, iris, pupil and lens. Use penlight and you may need to hold the upper lids. Assessment of ocular movement in all positions of gaze. Symmetry of Orbit Proptosis (exophthalmos), eye protrusion or Enophthalmos, eye retraction. Hertel exophthalmometer is used for measurement of degree of proptosis. Eyelids and Lid margins Examine the eyelids for signs of Ptosis, Retraction, Inflammation, Trauma or tumors. Lid margin position, Puncti, Rubbing lashes or Blepharitis. SLIT-LAMP Conjunctiva Bulbar, Palpebral, Fornices and Caruncle. Inspect the eye for any discharge. Palpate the pre-auricular lymph nodes. Hold eyelids to examine the bulbar conjunctiva and evert the lid to examine the palpebral conjunctiva or even double enversion of the lid to visualize the upper fornix. Lacrimal apparatus Inspection of normal anatomy. Dynamics of eyelid closure. Marginal tear strip. Tear film Break-up time (BUT). Schirmer’s test. Dye disappearance test. Regurgitation test. Rose Bengal test. Probing and irrigation. Sclera Sclera is visible beneath the conjunctiva as a white, opaque, fibrous structure. Thinning (scleromalecia), Scleritis, Episcleritis and scleral rupture. Cornea Slit-lamp biomicroscopy. Fluorescein stain. Rose Bengal stain. Corneal sensitivity. Keratoscopy (Placido disc, Topography). Corneal scraping. Iris and Pupil Slit-lamp examination (architecture of the iris, patches of atrophy, synechiae, abnormal opening, mass and neovascularization). Pupil: R (round), R (regular), R (reactive). Pupillary light reflex. Anterior Chamber & Angle Structure Estimation of depth of anterior chamber, AC, (Eclipse’ sign). AC reaction in the form of cells and flare (including Hypopyon). Visualization of angle structure using Goniolens. Examination of Ocular Muscles Evaluation in primary position of gaze as well as in cardinal positions of gaze. Crystalline Lens Cataract is the most common cause of decreased vision successfully treated in all of surgery. Pupillary dilatation. Slit-lamp biomicroscopy. Red reflex. Retina & Vitreous Indirect or Direct Ophthalmoscope. +90 or +78 dioptre lens, using slit-lamp. Dilate the pupil. Dim the light. Comment up on: Vitreous (clarity, hge., cells …etc.). Retina (optic disc, macula, retinal blood vessels and retinal background).