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眼科常用檢查
主治醫師教學
98-08-25
VS 譚超毅
Ocular Emergency
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Examinations.
Differential Diagnosis of “Red Eye”
Painless visual loss.
Trauma.
Ocular foreign body.
Taking History
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Previous vision in the affected eye.
Previous ocular trauma.
Present medication.
Details of present injury
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Blunt or penetrating
Projectile
Chemical property
Tools for Ocular Examination
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Snellen/Landolt C chart, near card
Trial frame, occluder, pinhole
Schiotz tonometry
Slit lamp
Ophthalmoscope
Topical Anesthetics
Topical Anesthetics Abuse
Fluorescein Stain
Cycloplegics for Examination
Visual Acuity
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“Vital sign” of the eye.
One of the most significant prognostic
indicators of eventual visual outcome.
Methods
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Snellen chart
Landolt C chart
Near card
Visual Acuity Check
Landolt C
Near Card
Visual Acuity Evaluations
Bare vision
Corrected vision
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Spectacles
Pinhole
Trial lens
Description
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20/20; 6/6; 1.0
Number of digit (ND), Counting finger (CF)
Hand motion (HM)
Light projection
Light perception (LP), Light sense (LS)
Visual Acuity Evaluations
Examples
 VA (OD): 1.0 (with pinhole (PH): 0.9)
 VA (OS): 0.1 (1.0x-3D=cyl-1.0D Axis 0)
 VA with PG: (OD) 0.8 (OS) 0.7
 ND 30 cm
 HM 60 cm
 LS (+)
 LS (-) under slit lamp/indirect ophthalmoscope light
Measurement of Intraocular Pressure
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Normal range of intraocular pressure: 6-21 mmHg
Indentation tonometry
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increased pressure or firmer eyes are less readily indented
with Schiotz plunger
low Schiotz reading  high pressure
Applanation tonometry
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In increased pressure or firmer eyes, more pressure are
required to flatten a small area of the cornea
high reading  high pressure
Measurement of Intraocular Pressure:
Schiotz
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The 5.5 weight is preset,
make sure that the plunger
moves freely
The Schiotz can be
autoclaved if necessary, but
usually the base is wiped
clean with an alcohol wipe.
Zero the instrument by
placing it on the steel plate
within the box, and ensure
that the arm reads "0"
Measurement of Intraocular
Pressure: Schiotz
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Place topical anesthesia on the
cornea and lie the patient flat.
Gently lower the plunger onto
cornea and keep the
instrument steady by holding
the handles; do not push the
instrument into the cornea.
Take the reading off the scale
and convert to mm Hg by table.
If the reading is at the low end
of the scale (high pressure)
add a second weight (7.5g or
10g) to the plunger and retake
Measurement of Intraocular Pressure
Applanation
Tono-Pen
Air-puff
Pupillary Examination
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Size of pupils
Configuration of pupils
Swinging light test
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Relative afferent pupillary defect (RAPD)
Marcus Gunn pupil
Light Reflex Pathway
Swinging Light Test: normal
Swinging Light Test: abnormal
Pupillary Examination
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Limitations
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Bilateral abnormalities of optic nerve
Marked opacities of the optic media
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Corneal opacity
Dense cataract
Vitreous hemorrhage
Diffuse retinal abnormality
Monocular patient
Extraocular Muscle Motility
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Orbital floor fracture
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Nerve Palsies
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Trauma is the most common cause of cranial nerve palsies
under the age of 45
CN 3 palsy
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May impair vertical gaze in affected eye
With minor head trauma is unlikely – if present may
indicate previously occult pathology
CN 4 palsy
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Often bilateral when secondary to trauma
Extraocular Muscle Motility
External Ocular Examination
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Review sensory and motor innervations of
lids
Inspect for ptosis, proptosis, entropion,
ectropion, common lid lesions (chalazion,
papilloma,basal cell ca.)
Review the location of the lacrimal gland,
puncta, canaliculi, nasolacrimal sac and duct
External Ocular Examination
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Have the patient follow a target with the eyes
to the extremes of gaze
Limbus should be in the same position in
both eyes for upward & downward gaze
Gently lift the upper lids in downgaze to
check the position of the cornea
Slit Lamp
Slit Lamp Examination
Anterior Segment Examination
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Examine from front to back anatomically:
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Lids, lashes and adnexal structures
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lids, lacrimal, lashes, sclera, conjunctiva, cornea,
iris, anterior chamber, lens
first to identify blepharitis etc.
Scleral examination
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can ask patient to look left/right/up/down in order
to view the entire sclera
Anterior Segment Examination
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Conjunctiva
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Cornea
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assessment for cataract
Testing for uveitis
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for keratitis, opacities or foreign bodies
Anterior Chamber depth screening
Lens
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ask patient to look left/right/up/down in order to view the
entire conjunctiva
cells or flare
Use of fluorescein and cobalt blue filter
Direct Ophthalmoscope
Normal Fundus
Fundoscopy
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Have the examining room dark
Give the patient a specific object on the wall on
which to fixate
Turn the ophthalmoscope on to a low-moderate
light intensity
Use the smallest aperture to look into an
undilated eye, and the largest aperture to
observe a dilated eye.
Use your right eye and right hand to look into the
patient's right eye (and your left eye/left hand for
the patient's left eye) Look through the
ophthalmoscope into the patient's eye from a
distance and find the red reflex
Fundoscopy
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Follow the red reflex into the eye at a small angle
towards the patient's nose
Focus on the optic disc
Follow the Superonasal arcade
Follow the Inferonasal arcade
Follow the Superotemporal arcade
Follow the Inferotemporal arcade
Focus on the macula (temporal to the optic disc)
Optic Atrophy
Major pathologies on Fundoscopy
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Hypertensive changes:
 Arteriolar spasm
 Exudates
 flame-shaped hemorrhages
 absence of venous
pulsations, ghost vessels
Atherosclerosis
Glaucoma
Diabetes
Occlusive Pathologies
Visual Field Testing
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Confrontation test
Amsler grid
Tangen screen
Kinetic visual field testing
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Goldmann
Static visual field testing
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Humphrey, Octopus
Confrontation Test
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Confrontation is better for identifying neurological
defects.
Examiner uses himself as a reference point
Check for fixation
Both patient and examiner should be using one eye
at a time.
Finger counting  suppression or decreased
sensitivity
Red target test  subtle neurological defects
Confrontation Test
Kinetic Perimetry
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Neurological VF loss
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if post-chiasmic, will be
homonymous
The Goldman is a
manual field machine
Automated Static Perimetry
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Automated is
necessary for
glaucoma diagnosis
and management
Glaucomatous VF loss
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follows a nerve fiber layer
bundle pattern
Automated Perimetry
Normal Visual Field
Glaucomatous Visual Field Defect
Tunnel Vision