Orientation

History taking
& Examination

Dr. Abdullah Al-Mousa

Dept. of Ophthalmology
College Of Medicine
King Saud University
 Orientation
OPT 432 Course
‫ار َوا ْْل َ ْفئِ َدةَ قَ ِليالً‬
‫ص َ‬ ‫شأ َ ُك ْم َو َجعَ َل لَ ُك ُم ال َّ‬
‫س ْم َع َو ْاْل َ ْب َ‬ ‫{قُ ْل ُه َو الَّ ِذي أَن َ‬
‫ون} [الملك‪]23:‬‬ ‫شك ُُر َ‬ ‫َّما ت َ ْ‬

‫ش ْيئا ً َو َج َع َل لَ ُك ُم‬ ‫ون أ ُ َّم َها ِت ُك ْم ال ت َ ْعلَ ُم َ‬

‫ون َ‬ ‫ط ِ‬ ‫َّللاُ أ َ ْخ َر َج ُك ْم ِم ْن بُ ُ‬
‫{ َو َّ‬
‫ار َو ْاْل َ ْفئِ َدةَ} [النحل‪.]78:‬‬ ‫ص َ‬‫س ْم َع َو ْاْل َ ْب َ‬
‫ال َّ‬
Ophthalmologist vs Optometrist
Why should
you be
interested in
the eye?
Why should
you be
interested in
the eye?
Objectives of this course

• To know the basic ophthalmic anatomy and

physiology.

• To know how to assess and manage common

ophthalmic diseases.
Objectives of this course

• To know how to triage and treat common

ophthalmic emergencies.

• How to use simple ophthalmic diagnostic

instruments.

• To acquire basic knowledge of some common

ophthalmic operations or procedures.
Components of the course
• Lectures
• Clinics
• Clinical sessions
• ER
Components of the course
• Lectures
• Clinics
• Clinical sessions
• ER
Components of the course
during covid-19
• Virtual Lectures

• Face to face Clinical sessions [marks]

• Final exam [MCQ+SAQ]

Marks distribution

Clinical
Final Final
skills
assessment MCQ Exam SAQ Exam

Marks 20 40 40
Lectures

1. History taking and ophthalmic exam

2. Basic anatomy and physiology of the Eye
3. Lid, Lacrimal, and Orbit Disorders
4. Ocular emergencies and red eye
5. Strabismus, Amblyopia and Leukocoria
6. Acute Visual Loss
Lectures

7. Chronic Visual Loss

8. Refractive Errors
9. Ocular manifestations of systemic diseases
10. Neuro-ophthalmology
11. Ocular Pharmacology and Toxicology
Clinical skill session/Assessment

1. Visual acuity, Tonometry, Ophthalmoscopy &

external exam [10 marks]

2. Visual field, Pupil Examination, Ocular motility &

alignment [10 marks]
Clinical skill session/Assessment
To minimize contact and to reduce time in the
hospital:
▪ Students will be required to prepare for the
clinical session by:
▪ Reading the provided handout Will be posted
▪ Watching the video links on blackboard
Clinical skill session/Assessment
▪ Will be given to each individual student group [10
students] by an assigned faculty member.
▪ This will be conducted in multipurpose hall in
building 3, ground level.
▪ Each clinical session will be 2 hours long.
Clinical skill session/Assessment
▪ The tutor will discuss the clinical skills with the
group using manikin heads to practice examination
skills.
▪ During the session he/she will assess each student
and give marks on her performance. [10 marks per
session ]
Clinical skill session/Assessment
Questions?
 Recommended textbooks
1. Required Text(s)
a. Lecture notes in Ophthalmology (latest edition)
By: Bruce James (published by Blackwell Science)
b. Basic Ophthalmology (latest edition)
By: Cynthia A. Bradford
(published by American Academy of Ophthalmology)
c. Practical Ophthalmology: A manual for Beginning
Residents (latest edition)
By: Fred M. Wilson (published by AAO)
 Recommended textbooks
1. Required Text(s)
a. Lecture notes in Ophthalmology (latest edition)
By: Bruce James (published by Blackwell Science)
b. Basic Ophthalmology (latest edition)
By: Cynthia A. Bradford
(published by American Academy of Ophthalmology)
c. Practical Ophthalmology: A manual for Beginning
Residents (latest edition)
By: Fred M. Wilson (published by AAO)
Recommended textbooks
 2. References

• Vaughan and Asbury’s general Ophthalmology

By: Paul Riordan-Eva (published by LANGE)
• Clinical Ophthalmology: A Systematic Approach
By : Jack T. Kanski (published by Butterworth Heinemann)
c. Electronic Materials & Web Sites

1. University electronic database /online Library

2. Lecture handouts on blackboard
3. PubMed
4. Medscape
5. The digital journal of ophthalmology (djo.harvard.edu)
6. up to date.com
7. E medicine
8. Eyewiki.org
9. Ophthobook [timroot.com]
Clinic
Basic eye clinic
More advanced equipment
Ophthalmic imaging
Ophthalmic imaging
Ophthalmic imaging
Modern eye clinic
The Visual Pathway
Cornea
Anterior Chamber
Iris
Lens

Vitreous

Retina
The Visual Pathway

RGCs

*Phototransduction:
photoreceptors (rods and
cones)
*Image processing:
By horizontal, bipolar,
amacrine and RGCs
*Output to optic nerve:
Nerve Fibers Via RGCs and
nerve fiber layer
The Visual Pathway

RGCs

*Phototransduction:
photoreceptors (rods and
cones)
*Image processing:
By horizontal, bipolar,
amacrine and RGCs
*Output to optic nerve:
Nerve Fibers Via RGCs and
nerve fiber layer
The Visual Pathway
Retina

Optic Nerve

Optic Chiasm

Optic tract

Lateral Geniculate
Nucleus

Primary Visual Cortex

“The eye is the window to the
body”
• The eye is so intimately connected with the rest
of the body that it reveals enormous amount of
general information.

• Eye is the only part of the body where blood

vessels and central nervous system tissues can
be viewed directly.
Examples
Neurological connections
• The 12 cranial nerves provide us with a large
amount of information about the brain.
❖ Of these , the eye examination evaluates CN II,
III, IV, V, VI, VII, VIII.

• In addition, they provide information about the

autonomic pathways. (sympathetic
/parasympathetic)
The retina and optic nerve
Are physical extensions of the brain.

The visual pathways:

Extends from front to back across the brain can be studied
easily and safely using perimetry.

Perimetry can differentiates accurately between lesions of

the temporal, parietal, and occipital lobes.
• In addition,
▪ the ON has important clinical relationships to
the pituitary gland, the middle ventricles, the
venous sinuses and bony structures of base of
the skull.
ON has the diagnostically
useful capability of swelling
with ↑ ICP (papilledema).

OR
visibly pale (optic atrophy)
when its nerve fibers
damaged at any point from
Retina → LGB.
The study of CN III, IV, V, VI
a clinician can evaluate:
1. The brain stem
2. Cavernous sinus
3. Orbital apex
Unilateral dilated pupil after head injury → pressure
on pupil constrictor fibers of CN III.

CN VI palsy → mastoid infection (petrous ridge)

Parotid gland, Inner ear disease → CN VII palsy

Nystagmus → CN VIII disease

Vascular connections
❖Venous flow disorders:
cavernous sinus thrombosis
OR
carotid cavernous fistula

(orbital congestion)
Arterial emboli
• can reach the
retina from
carotid artery, Hypertension
heart valves,
subacute
endocarditis.

Systemic Systemic
coagulopathy vasculitis
❖ Hematological disorders of all types can
manifest in the fundus.

❖Metabolic disorders can affect the eye:

DM :DR, cataract, refractive error, ophthalmoplegia.
Hyperthyroidism : Graves disease
Wilson’s disease. KF ring
❖Thyroid eye disease:
Exophthalmos, Lid retraction.

❖Infections:
(Syphilis, Toxoplasmosis & Rubella)
❖Mucocutaneous disorders:
SJS, pemphigus

❖Elastic tissue disorders:

(Pseudoxanthoma elasticum)

❖ Allergy disorders:
Vernal keratoconjuctivitis
❖ The eye is a delicate indicator of poisoning:
-Morphine addict → miotic pupil
-Lead poisoning, vitamin A intoxication
→ papilledema
90% of our information reaches our brain
via sight.

Unfortunately, of all the parts of the body,

the eye is the most vulnerable to minor
injury.
What are the components of a
comprehensive ophthalmic
evaluation?
➢Obtain an ocular and systemic history.

➢Identify risk factors for ocular and systemic

disease.

➢look for symptoms and signs of ocular or

systemic disease.
➢ reach a provisional diagnosis

➢Initiate an appropriate response:

e.g. further diagnostic tests, treatment,
or referral.
HISTORY
History by skilled person can arrive at the
proper diagnosis in 90% of patients
 It gives vital guidance for:
(a) physical examination
(b) laboratory work
(c) Therapy

❖Failure to take history can lead to missing

vision or life-threatening conditions.
Chief complaint:’’The patient’s own words’’

‘’she cannot see with the RE’’

You should not come to conclusion that her
problem is nearsightedness and write down
“Myopia of RE”.

• The patient needs will not be satisfied until

he/she has received an acceptable explanation of
the meaning of the chief complaint and its proper
management.
History of the Present Illness:

Detailed description of the chief complaint to

understand the symptoms and course of the
disorder.

Listen and question and then write down in

orderly sequence that make sense to you.
 * The time sequence
when, How fast, what order did events occur?
* Frequency, intermittency
* location, Laterality
* Severity
* Associated symptoms
* Documentation (old records, photo)
e.g ptosis, proptosis, VII N palsy.

➢ Gradual painless decrease vision both eyes for 1y.

➢ Sudden painless decrease vision re for 10 min.
 “cannot see with RE”!!
• ? Only distance vision blurred.
• ? Blind spot is present in the center of VF
• ? Right side of VF of the RE lost
• ? Right VF of both eyes lost
• ? A diffuse haze obscures the entire field of RE

❖Each of these has different diagnostic implication

❖Most pt. has difficulty providing precise and concise
description
Disturbances of vision:
• Blurred or decreased central vision
• Decreased peripheral vision. (glaucoma)
• Altered image size.
(micropsia, macropsia, metamorphopsia).
• Diplopia (monocular, binocular)
• Floaters
• Photopsia (flash of light)
• Color vision abnormalities.
• Dark adaptation problems.
• Blindness
(ocular, cortical).
• Oscillopsia
(shaking of images).
Ocular pain or discomfort:
• Foreign body sensation
• Ciliary pain
– (aching, severe pain in or around the eye, often radiating to the
ipsilateral forehead, molar area)
• Photophobia
• Headache
• Burning
• Dryness
• Itching: patient rub the eye vigorously (allergy)
• Asthenopia (eye strain)
 Abnormal ocular secretions:

• Lacrimation, epiphora
• Dryness
• Discharge
(purulent, mucopurulent, mucoid,
watery)
• Redness, opacities,
masses

• Anisocoria
Family history:

Many eye conditions are inherited

Refractive error, glaucoma, strabismus, retinoblastoma,
neoplasia & vascular disorders

• Familial systemic disease can be helpful in

ophthalmic evaluation and diagnosis
Atopy, thyroid diseases, DM, some malignancies.
• Ask about any eye
problem in the family
background?

• Ask specifically about

corneal diseases,
glaucoma, cataract,
retinal diseases or
other heritable ocular
conditions.
Ask questions designed to confirm or exclude your
tentative diagnosis
- significant positive
- significant negative

predict the physical and lab. finding likely to be

present.

any discrepancy between the history and physical

examination requires explanation
Ophthalmic examination
Ophthalmic
examination
 Ophthalmic examination
• Visual acuity
• External examination
• Motility and alignment
• Pupil examination
• Slit lamp biomicroscopy
• Tonometry
• Ophthalmoscopy
• Gonioscopy
• Retinoscopes
Visual acuity:

• It is a vital sign (MUST)

• Good vision intact neurological visual pathology

structurally healthy eye

Proper focus

• Subjective
 How to test vision?

• Display of different –sized targets

shown at a standard distance from
the eye.
• Snellen chart.
• 20/20, 6/6
• Uncorrected, corrected
Testing poor vision:
• If the patient is unable to read the largest
letter <(20/200)
• Move the patient closer e.g. 5/200
• If patient cannot read:
- count fingers (CF)
- hand motion (HM)
- Light perception (LP)
- No light perception (NLP)
External examination:

• Evaluate by gross
inspection and
palpation.

• Ocular adnexa. (lid,

periocular area)

• Skin lesions,
growths,
inflammatory lesions.
• Ptosis

• Proptosis,
exophthalmos,
enophthalmos
• Palpation of bony rim,
periocular soft tissue.

• General facial
examination e.g.
enlarged preauricular
lymph node, temporal
artery prominence.
Ocular motility:

Evaluate - Alignment
- Movements
• Misalignment of the
eyes
 Movement:
• Follow a target with both eyes in each of the
four cardinal directions of gaze.

• Note - speed
- smoothness
- range
-symmetry
-unsteadiness of fixation
e.g nystagmus
Pupils:

Examine for size, shape,

reactivity to both light
and accommodation.

• Direct response and

consensual response.
• Afferent pupillary defect
(Marcus Gunn pupil)
• Causes of Pupillary abnormalities:
- neurologic disease
- previous inflammation – adhesion
- acute intraocular inflammation - spasm
- atony
- prior surgical trauma
- effect of systemic or eye medication
- benign variation of normal
Slit lamp examination:

Is a table-mounted binocular
microscope with special
illumination source.

A linear slit beam of light is

projected onto the globe –
optic cross section of the
eye.
• Slit lamp alone, the
anterior half of the
global (anterior
segment) can be
visualized.
Tonometry:
– The globe is a closed compartment with
constant circulation of aqueous humor.

– This maintains the shape, and relatively

uniform pressure within the globe.

– Normal pressure 10 – 21 mmHg.

Types of tonometry:

Schiotz tonometer
Goldmann applanation
tonometer
Tonopen
Ophthalmoscopy:

➢ Direct ophthalmoscopy:
➢ handheld instrument.
➢ standard part of the general
medical examination.
➢ Portable
Indirect ophthalmoscope
Indirect Ophthalmoscoy:

1. provide much wider field of view

2. less magnification (3.5X with 20D lens)
3. brighter light source – better view.
4. Binocular – steroscopic view.
5. Allow entire retina examination till the
periphery.
Disadvantage:
1. Inverted retinal image.
2. Brighter light is uncomfortable to the
patient.
– Special lenses:
- Gonio lens
- wide field contact lenses
allow evaluation of the
posterior segment.
Retinoscope
Retinoscopy