Radiology Update

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HOW TO EXAMINE AN EYE
Dr Peter Beckingsale FRANZCO
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• Acknowledgment to Dr Anthony Pane for much of
  the original text in this presentation

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History

• Presenting complaint
• one or both eyes?
• rapidity of onset? eg loss of vision over 2
  hours much more worrying than gradual loss over 1
  year
• pain - scratchy at the front of eye, or deep
  inside the eye?
• mechanism of injury?
• hammering / grinding metal felt something hit
  the eye ? penetrating eye injury until proven
  otherwise by examination / X ray / CT

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History

• specific questions for painless visual loss
  without history of trauma
• flashes / floaters / field loss? (retinal
  detachment)
• headaches / scalp tenderness / jaw pain etc
  (temporal arteritis)
• distortion of straight lines (metamorphopsia -
  macular disease)
• loss of part of the field of vision only
  (retinal, optic nerve or brain disease)
• are there any OTHER injuries that need attention
  as well as the eye? (eg if patient was knocked
  out, do they first need a CT head to exclude
  intracranial bleed?)

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History

• Previous ophthalmic history
• previous eye disease / injuries / operations /
  laser / spectacle or contact lens wear
• contact lens wearers are at much higher risk of
  dangerous corneal infections

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Bacterial Keratitis
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History

• Relevant previous medical / surgical history
• especially
• diabetes (diabetic retinopathy)
• coagulopathies, aspirin, warfarin (bleeding in
  eye / vascular occlusions)
• malignancy eg leukemia, melanoma (infiltration of
  eye or visual areas of brain)
• systemic infection, immunosuppression or
  immunodeficiency
• carotid stenosis, AF, heart murmurs, artificial
  heart valves (emboli to retina)

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History

• medications that can cause eye complications eg
  hydroxychloroquine

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History

• Family history
• of eye disease eg of chronic open-angle glaucoma

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Examination

• First measure the visual acuity (VA) !!!
• viewing a Snellen (letter) chart 6 metres away
• one eye at a time (securely cover the other eye)
• with nothing in front of the tested eye
• wearing their bifocals or the glasses they use to
  look in the DISTANCE (not reading glasses!) (or
  test with contact lenses in - but take out lenses
  before using flouroscein and rinse eyes well
  afterwards, as it may stain soft lenses)
• looking through a PINHOLE (commercial pinhole
  glasses or make one yourself by sticking the
  point of a biro through a piece of paper)

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Examination

• if the lowest line they can read is the 9 line,
  write 6/9 and say six nine if they can
  only read down to the 24 line, write 6/24 and
  say six twenty-four
• if they cant read any letters at all
• can they count your fingers reliably? (count
  fingers, CF)
• can they see your hand moving in front of their
  eye? (hand movements, HM)
• can they tell you when you shine a bright torch
  into their eye? (perception of light / PL
  if not no perception of light / NPL)

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Examination

• Look at the eye with a torch - is it red? does
  it look like the other eye?
• also look for
• proptosis (the eye is bulging forwards)
• squint (the eye is turned in a different
  direction when looking straight ahead)

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Scleritis
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Examination

• Test the pupils
• are both pupils the same size?
• shine a bright torch into first the right eye
  then the left - do both pupils constrict to
  light?

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Examination

• swinging torch test for a Relative Afferent
  Pupillary Defect (RAPD)
• swing the torch alternately back and forth
  between the two eyes
• a normal response is for each pupil to constrict
  slightly when the torch is shone on it
• an RAPD (abnormal response) is present in an eye
  when the torch is shone onto one eye and the
  pupil DILATES - this signifies serious disease of
  the retina or optic nerve

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Examination

• Test the visual fields
• sit in front of the patient, get them to cover
  their left eye and stare into your left eye -
  test ability to count fingers in all four
  quadrants and to recognise a target moving in
  from the periphery - repeat for the other eye

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Examination

• Test the eye movements
• check that both eyes have a full range of
  movement looking in all directions
• ask the patient if they see double at any stage

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Esotropia
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Examination

• Look at the front of the eyes with the slit lamp
  microscope
• -make sure you can turn on / use the slit lamp!
• -be systematic

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Examination

• eyelids
• if the patient complains of a scratchy sensation
• check for inturned eyelashes rubbing on the
  cornea
• always evert the eyelids (flip the top eyelid
  over pull the bottom eyelid down) and look at
  their back surfaces

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Examination

• cornea
• are there any foreign bodies / scratches /
  lacerations?
• is the cornea crystal clear, or is there an
  infiltrate? (opaque yellow or white patch within
  the substance of the cornea)
• put a drop of flouroscein (a yellow stain) into
  the eye turn the light onto the blue setting -
  a corneal epithelial defect will stain bright
  fluorescent yellow - also look at the conjunctiva
  (clear skin over the sclera) under the blue light
  for defects there - then turn the light back to
  white

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Corneal Foreign Body
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Dendritic Ulcer (HSV)
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Examination

• conjunctiva
• look for foreign bodies / lacerations etc
• is the eye INJECTED (red due to swollen blood
  vessels?)
• CILIARY injection - red ring around the edge of
  the cornea
• CONJUNCTIVAL injection - whole eye uniformly red,
  ? with distance away from cornea
• sclera look for lacerations etc

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Neonatal Conjunctivitis
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Examination

• anterior chamber the fluid-filled space between
  the back of the cornea and the front of the
  iris - normally completely clear
• turn the light beam up to its highest intensity,
  make it about 3mm high and 1mm wide, and shoot it
  through the anterior chamber at about 45 degrees
  - look carefully at the beam on high
  magnification

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Examination

• normally the beam is invisible in the anterior
  chamber
• abnormally, eg in iritis
• cells floating specks in the beam - like
  specks of dust in a sunbeam
• flare you can see the beam itself - like car
  headlights through fog
• you may also see a fluid level sitting in the
  bottom of the anterior chamber
• yellow pus hypopyon
• red blood hyphaema

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Hypopyon
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Hyphaema
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Examination

• iris look for lacerations, foreign bodies etc
• in iritis, parts of the iris can be stuck down
  onto the anterior lens surface posterior
  synechiae
• lens impossible to examine properly unless the
  pupil is dilated

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Cataract
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Examination

• Measure the intra-ocular pressure with Schiotz
  tonometer or Tonopen
• except in suspected penetrating eye injury
• normal IOP is 12 - 21 mmHg

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Examination

• Dilate the pupil/s
• it is impossible to get a good view of anything
  except the optic disc if you dont dilate the
  pupil with dilating drops
• if you suspect a serious eye problem, seek
  ophthalmic opinion before dilating the pupils -
  if you dilate BOTH eyes, the ophthalmologist will
  be unable to assess for a RAPD - he / she may
  advise dilating only the affected eye

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Examination

• a good dilating drop to use is tropicamide
  (Mydriacyl) 1 - put one drop in the eye to be
  dilated every five minutes until three drops
  total have been used - warn the patient this will
  make their vision bright blurry for about 8
  hours tell them not to drive

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Examination

• Look at the back of the eyes with the direct
  ophthalmoscope
• -be systematic - look at
• optic disc
• colour
• cup-disc ratio (normally lt 0.5)
• is it raised? (as in papilloedema)

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Glaucomatous Disc Cupping
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Optic Nerve Head Oedema
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Examination

• vessels
• blockages, dilation, tortuosity
• silver wiring, AV nipping etc
• abnormal new vessels eg in diabetes
• macula
• peripheral retina haemorrhage, exudates,
  detachment?

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Macular Exudate (ARMD)
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Retinal Haemorrhage (CRVO)
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How to examine an eye witha torch and a newspaper

• You will often find yourself in a situation where
  you have a patient with a red eye or blurred
  vision and no equipment to examine them with -
  eg
• - a public hospital ward
• - a peripheral hospital
• - a GP surgery
• This is not the ideal situation, but this is the
  real world.

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WHAT DO YOU DO?

• You do the best you can with what you have.
  Please DONT GIVE UP STRAIGHT AWAY - YOU CAN FIND
  OUT A LOT ABOUT AN EYE JUST BY A CAREFUL HISTORY
  AND EXTERNAL EXAMINATION. You may not get enough
  information for a firm diagnosis, but you will be
  able to talk intelligently to an ophthalmologist
  about the problem.

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WHAT DO YOU DO?

• This is much preferred to the common options
• -give up immediately and prescribe Chlorsig
• -give up immediately and refer non-urgently (with
  no firm idea of whether the situation is urgent
  or not)

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HISTORY

• What can go wrong with an eye?
• it loses vision - central or peripheral
• it doesnt move properly (the two eyes are not
  lined up) ? double vision
• it becomes red
• / or it becomes painful
• surface pain (scratchy pain - foreign body
  sensation)
• deep / aching pain

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• So ASK the patient about these symptoms. A red
  eye with loss of vision or pain is more likely to
  be an emergency than a red eye with normal vision
  and mild irritation.
• SEVERITY DURATION of symptoms are also
  important eg 6 hours of profound visual loss in
  one eye needs urgent referral, while 6 months of
  slow decline of vision may just be due to
  cataract.

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WHAT IS THE CENTRAL VISION?

• You can get a good idea of this WITHOUT an
  expensive Snellen VA chart
• get the patient to put on their glasses, if they
  normally wear glasses for reading
• cover one eye
• ask the patient to read the fine print of a
  newspaper (or medical textbook, or obs chart, or
  whatever) for you. If they cant, can they see
  the headlines? If not, can they count your
  fingers, see your hand moving, or see a light?
• then cover the other eye and repeat

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WHAT IS THE SIDE VISION?

• Test the patients peripheral vision to
  confrontation - one eye at a time.
• If both sides abnormal, brain tumor or other
  brain problem possible.
• If one side abnormal, possible eye problem eg
  retinal detachment.

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CAN THE EYES MOVE?

• ask about double vision
• have the patient follow a target eg a pen in all
  directions see if the eyes move fully in all
  directions

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DO THE PUPILS WORK EQUALLY ON THE SWINGING TORCH
TEST?

• Swing the brightest light you can find
  repetitively from eye to eye (about 1 sec each
  eye) after asking the patient to stare into the
  distance.
• Normally, each pupil will briefly get smaller as
  the light is shone on it. If it dilates instead,
  there is something bad going on.
• If you have problems seeing the pupil reaction,
  try turning the room lights out.

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DO THE EYES LOOK NORMAL TO YOU?

• Have a close look with your torch. If you have a
  magnifying glass, use it. In particular
• is the cornea (clear bit) clear?
• is the sclera (white bit) white, or is the eye
  red? If its red, is it just a bit pink or
  really red?
• Is there a foreign body eg a bit of metal on the
  eye?
• Is there blood behind the cornea (hyphaema)?

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IS THERE SOMETHING UNDER THE EYELIDS?

• If the patient is complaining of a scratchy eye,
  flip over the top eyelids and look for something
  stuck underneath.

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EXTRA BITS YOU CAN DO IF YOURE LUCKY ENOUGH TO
HAVE THE GEAR

• stain the cornea with fluoroscein drops and look
  at them under a blue light (you dont need a
  fancy blue filter - a bit of blue cellophane over
  a torch will do). If a patch of the cornea
  lights up fluorescent yellow, thats abnormal and
  could be a scratch or ulcer.
• look at the front of the eye with a slit lamp
• look at the back of the eye with an
  ophthalmoscope