CLINICAL EXAM FOR OPHTHALMOLOGY.

1) Slides. (15 marks)

Clinical picture + Questions. Note on Exam : The picture of the slides can be of anything. Expect pictures of cases with complications (eg: corneal rupture with iris prolapse) and the pictures are usually from your lectures and revision class. The short questions are simple, straight forward questions.

2) Techniques.
I. II. III. IV. V. VI. VII. Pupillary reaction (swinging flashlight test) Confrontation test Regurge test Muscle balance & Ocular Motility Visual Acuity Ptosis Assesment Orbicularis Muscle Examination.

Note on Exam : You will be asked to perform only one of these techniques. It is important to know the key method of each technique and to know the normal values of outcomes. (Eg: Normal Margin Reflex Distance is 4mm). It is also possible to have normal patients with normal results.

3) Clinical cases.
I. II. III. IV. V. VI. VII. VIII. IX. X. Cataract (senile) Pseudophakia Aphakia Corneal Opacities Keratoconus Squint Ptosis Entropion, Ectropion, Trichiasis, Rubbing Lashes. Pterygeum, Pinguecula Chalazion, Xanthelasma

Note on Exam : The patient will be a straightforward case without any complications. Also remember to mention about arcus senilis and pannus siccus. Both performing techniques and clinical cases will have 10 marks in total. And we have oral examination for 15 marks too :D

Techniques for Clinical Exam.

1)

Visual Acuity.
Chart Counting Fingers Hand Movement. Perception of Light Projection of Light.

*First test counting fingers at 50 cm, if the patient: - can see : test CF farther or chart - cannot see : test CF closer or HM. *Or you can start from the chart: 1. 2. 3. 4. Let the patient sit 6 meters from the chart. Ask him to close one eye. If he cannot see the largest object on the chart, bring the chart to 5m. If he still couldnt see, bring it closer to the patient. (4m, 3m, 2m, 1m) The least vision in fraction is 1/60. After this you have to use CF in cm.

Chart

Counting Fingers

1. Ask the patient to count fingers with one eye closed. 2. Write down the distance at which he could count fingers. (eg: CF 60cm) 3. Least distance you can CF is 20cm. Closer than this you need to use HM.

Hand Movement

1. Wave your hand in front of the patients eye. 2. If he sees the movement, his vision is HM. 3. If he couldnt see the movement, proceed to Perception of Light and Projection of Light.

Perception Of Light

1. Shine torch directly in front of his eye. 2. If he can see the light, write PL. (perception of light) and proceed to perform Projection of Light. 3. If he cannot see the light, write no PL. (no perception of light)

Projection of Light

1. Shine torch from his nasal and temporal side. 2. If he can see light from both sides, write Good Projection of Light. 3. If he couldnt see from even one side, write Bad Projection of Light.

2)

Muscle Balance and Ocular Motility.

6 Cardinal Positions.

a) b) c) d)

Sit at the same level as the patient and fix his head. (not to move the head) Move your torch accordingly to the 6 cardinal positions. After each position, return to primary position (in the middle of his two eyes) To check for downward position, hold the patients eyelids up. OCULAR MOTILITY

Ductions.
Motility of one eye.

Cover one eye & check for 6 cardinal positions of the uncovered eye. Check for the other eye Ask patient to look with both eyes & check for 6 cardinal positions. Convergence -Move your torch close towards patients eyes. Divergence -Move your torch away from patients eyes.

Versions.
Motility of both eye moving in same direction

Vergences
Motility of both eye moving in opposite direction

How to Comment: Ortophoric (normal muscle balance) and Free Ocular Motility if the patients eye is able to move in all directions. If he wasnt able to move his eye in any direction, mention that he has limitation of movement to that particular direction.

3)

Regurge Test.
Evert lower eyelid to expose the punctum. Press firmly on lacrimal sac (direction: backwards, medially, upwards) Check if any fluid comes out of the punctum.

How to Comment: Positive Regurge test if few drops of fluid come out. If not, he is considered Negative Regurge Test.

4)

Confrontation Test
Sit at the same level with the patient Ask patient to close the eye parallel to eye you are closing (if you are closing right eye, the patient has to close his left eye) Start moving your hand from away/periphery. (move your fingers too for best stimulus) Ask the patient to tell when he first sees your finger. First check the temporal field of the patient. Next check the nasal field. To check for nasal field, you have to switch your hands to prevent crossing of hands over the field. Compare patients visual field to your own field.

How to Comment: Normal Visual field if he is normal or Tubular Field/ Defect in Visual field in Glaucoma. 5)

Ptosis Examination. (the most common test asked is Margin Reflex and Levator Function)
Test Ptosis Evaluation Mechanism Normal Value

Margin Reflex Distance

Measure the distance from the upper eyelid margin to the corneal reflex in primary gaze.

Normal: 4-5mm. Ptosis: <4mm

Palpebral Fissure Height

Distance between upper lid margin to lower lid margin passing through the center of pupil in primary gaze.

Normal: 9-10mm Ptosis: <9mm

Upper Lid Crease

Crease height is the distance from the upper eyelid margin to the upper eyelid crease in downward gaze.

Normal: 5-10 mm

I. Ask the patient to look down. II. Gently press above his eyebrow with one finger. III. Put the zero mark on the margin of the upper eyelid Levator Function while he is still looking down. IV. Ask the patient to look up as much as he could. V. Measure the movement of the upper lid margin.

Good (8 mm) Fair (5-7 mm) Poor (4 mm)

6)

Orbicularis Oculi Muscle Examination

a) Palpebral Portion. (Function for gentle closure of the lid) - Sit at the same level of the patient - Ask Patient to close his eye gently as if sleeping - Elevate his chin up - Detect the state of the palpebral fissure whether completely closed or incompletely lagophthalmos b) Orbital Portion. (Function for forcible contraction of lid) - Ask the patient to squeeze his eyes shut - Ask him to resist your attempt to open his eye. - Normally you cannot open his eye.

How to Comment: Patient has normal orbicularis oculi muscle function if he is normal. Or patient has deficient orbicularis oculi muscle function if he is not normal.

7)

Pupillary Reflex: Swinging Flashlight test.

Fix the patients position, ask him to look at far object (to prevent near reflex) You have to stand by the patients side and to hold the torch from the side to prevent near reflex. Start swinging your torch from right to left eye and pause for a few seconds on each eye to examine the pupil reflex. Normal Eye Right Pupil Reflex Left Description Size 4 mm Right normal Constrict (consensual) Constrict (direct) Normal Left Normal Constrict (direct) Constrict (consensual) Normal

2 mm

2 mm

4 mm

Right Optic Nerve Atrophy Right Pupil Reflex Left Description Size 4 mm Right normal Constrict (consensual) Dilating (no stimulus) Normal Left Normal Constrict (direct) Dilating (no stimulus) Normal

2 mm

3 mm

4 mm

In RAPD (Relative Afferent Pupillary Defect) : when light is shone on intact left eye, the pupil constrict on both eyes due to direct affect on left eye and preserved consensual affect on right eye. But when the light is swung to right eye, the pupil appears to be dilating instead of constricting. This is due to no stimulus is received because of a defect in afferent pathway in right eye. Hence, no direct affect on right eye and no consensual affect to left eye. How to Comment: normal Regular, Reactive, Rounded pupil in normal intact afferent pathway. Or the patient has RAPD in eyes with defective afferent pathway.