Junior Intern Review
Carlo Galang, MD
REMINDERS
CHILL tfo
Med Bag
WORKING penlight
Millimeter ruler
Jaeger (near vision) chart
Occluder with pinhole
Books
Post-its/markers on pages
Notebook
PRAY
General data
Name, age, sex, occupation
Chief complaint
Blurring of vision, redness, eye discomfort
History of Present Illness
When did it start? Sudden or gradual? Character? Precipitating/
alleviating factors?
Past Medical History
Hypertension, DM, PTB, thyroid disease, allergy, glaucoma,
autoimmune disease,
Visual Acuity
External Eye Exam, EOMs
Fundoscopy
DISTANCE
SC= without
NEAR
correction
SC= without correction
PH= pinhole CC= with correction
CC= with correction
20/63
Visual Acuity
20/200
20/160
20/125
20/100
20/80
20/63
20/20
Always make sure the other eye not being tested is covered!
20/20
Visual Acuity
20/200
20/160
20/125
20/100
20/80
20/63
20/20
Amsler Grid
Central 20 degrees of visual field
Normal reading distance
Corrected visual acuity for near – READING GLASSES
External Eye Exam
Lids – swelling, masses, ptosis?
Lashes – misdirected, extra rows, matting?
Conjunctiva – hyperemic?
Sclera – icteric?
Cornea – clear? Hazy?
Anterior chamber – deep?
Iris – pigmented? Rubeosis?
Pupils – Size? Equal? Reactive to Light? RAPD?
Lens – clear? Slightly opaque?
Common Ocular Symptoms
Abnormalities of vision
Blurring of vision
Double vision
Abnormalities of ocular appearance
Redness
Fleshy mass on the cornea
Lesions on the eyelids; discharge
Abnormalities of ocular sensation
Pain
Discomfort; itching; dryness
Foreign body
ERRORS OF REFRACTION
Myopia
Hyperopia
Astigmatism
Presbyopia
Pinhole Acuity Test
Pinhole admits only central rays of light, which do not
require refraction by cornea or lens
If acuity improves by 2 or more lines, patient likely has EOR
If acuity DOES NOT improve, patient may have non-
refractive causes for the reduced VA
Causes of Refractive Errors
Eye length
Corneal curvature
Lens curvature
Myopia
Image of distant objects focuses in front of the retina.
Eye is longer than the average (Axial Myopia)
Refractive elements have more refraction than average
(Curvature/Refractive Myopia)
Hyperopia
Image is focused behind the retina.
Eye is shorter than average (Axial Hyperopia)
Refractive elements have less power (Refractive Hyperopia)
Astigmatism
Eye produces an image with multiple focal points/lines
Refractive States of the Eye
Emmetropia
Ametropia
Myopia (nearsighted)
Hyperopia (farsighted)
Astigmatism
Presbyopia
Accomodation – eye changes refractive power by altering the
shape of its crystalline lens.
Loss of accommodative ability of crystalline lens
Management
Use of lenses to achiever the best possible acuity on distance
and near vision tests.
Subjective
Objective = retinoscopy
Prisms (technically not lenses)
Wedge of refracting material with triangular cross section,
deviates light toward its base.
Image displaced toward the apex.
Spherical lenses can be thought of as paired prisms
Convergent (+) – base to base
Divergent (-) – apex to apex
Prism Diopters (PD) – deviates parallel rays of light 1 cm
when measured at a distance of 1m from prism.
PD = 1cm/deviating distance(m)
Types of Lenses
Spheres
Same curvature over its entire surface, same power in all
meridians
CONVE(x) = CONVErge = plus (+)
1 diopter plus power converges parallel rays of light to focus at
1m from the lens.
Concave = diverge = minus (-)
Parallel light rays enter the lens appear to diverge
Virtual image is considered to appear at a focal point in front of
the lens
conveX conCAVE
Cylindrical
Vergence power in only one meridian
Power is perpendicular to the axis of meridian
Focuses light rays to a line
Spherocylindrical
Focuses light in two line foci
Shape of light rays = conoid of Sturm
Between the two-line foci = circle of least confusion (best
over-all focus for a spherocylindrical lens)
Case: 19/M
CC: blurring of vision, OU
HPI: difficulty reading at far, “fuzzy”. Noticed during class,
difficulty seeing words written on the board/powerpoint.
PE:
VA:
OD OS
SC 20/100 | J1 20/125 | J1
PH 20/30 -2 20/40 +2
CC No corrective lenses No corrective lenses
Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, lens,
EOMs
Fundoscopy: +ROR, clear media, distinct disc margins, AV 2:3,
CD 0.3
CATARACT
Any opacity in the lens
Aggregation or denaturation of lens proteins
From oxidative damage, ultraviolet light
Mature – all lens protein are opaque
Immature – has some transparent protein
Hypermature – cortical proteins have become liquid
Morgagnian – lens nucleus floats in the capsular bag
Causes; symptoms
A – Aging
Nuclear sclerosis
May have improved near vision w/o glasses (second sight)
Monocular diplopia
B – Blow out (TRAUMA)
Foreign body to the lens; blunt trauma (star-shaped)
C – Congenital – Pedia (remove part of the PC)
Rubella, disorders of metabolism
D – Diabetes, drugs
Cortical
Corticosteroids, phenothiazines
After-cataract – opacification of posterior capsule (proliferating
epithelium)
Significant problem in almost all pedia patients
Treatment
Surgery
Phacoemulsification
Extracapsular Cataract Extraction
Intracapsular Cataract Extraction
Mechanical irrigation/aspiration handpiece
Case: 64/F
CC: blurring of vision, OU
HPI: 3 years progressive worsening of vision, “cloudy”. +glare
when seeing car headlights.
PE:
VA:
OD OS
SC 20/100 | J8 20/125 | J8
PH 20/50 -2 20/63 +2
CC J1 J1
Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, LENS,
EOMs
Fundoscopy: +faint ROR, slightly hazy media, distinct disc
margins, AV 2:3, CD 0.3
DRY EYE SYNDROME
Tears
7-19 um thick, covers corneal and conjunctival epithelium.
Wet and protect surface of cornea
Inhibit growth of microorganisms, antimicrobial enzymes
Contains IgA, IgG, IgE
Corneal nutrition, K, Na, Cl
Causes
Hypofunction of lacrimal gland Sjogren’s, Irridation, Mumps
Mucin deficiency – SJS, chemical burns, anti-muscarinics
Lipid deficiency – lid margin scarring, blepharitis
Defective spreading of Tear Film – pterygium, decreased blinking
Monomolecular film of lipid
from Meibomian glands.
Retards evaporation
From major and minor
lacrimal glands.
Contains salts and proteins
Glycoprotein, overlies
cornea and conjunctiva.
Epithelial cells composed of
lipoprotein – mucin partly
absorbed; anchored by
microvilli
Symptoms; Signs
Itchy, sandy, foreign body sensation
Redness, stinging sensation, pain
Absent tear meniscus
Tear Break-up Time
Dry spots
>10 seconds = Normal
Treatment
Artificial tears
Carboxymethylcellulose 1gtt 4-6x/day
Hypromellose
Sodium hyaluronate
Preservative-free artificial tears
Ointment/eye gel
TID or ODHS
May cause blurring of vision
Blepharitis – lid hygiene and topical antibiotics
Severe – punctal plugs, electrocautery.
Case: 24/F
CC: foreign body sensation
HPI: 3 months foreign body sensation, noticed when watching
television or when patient is reading. Occasional redness,
itchiness.
PE:
VA:
OD OS
SC 20/20| J1 20/20| J1
PH 20/20 20/20
CC No corrective lenses No corrective lenses
Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, lens,
EOMs
Fundoscopy: +ROR, clear media, distinct disc margins, AV 2:3,
CD 0.3
CONJUNCTIVITIS
Viral
Bacterial
Allergic
Visual Acuity
Distance
Near
Amsler
Slit-Lamp Examination
Red/Pink Eye
What do we rule out?
Signs/Symptoms
Pruritus, discharge, redness, foreign body sensation, fullness
around the eyes, pain – cornea may be affected
Hyperemia, lacrimation, papillary hypertrophy
Edema of conjunctival stroma
Hypertrophy of lymphoid layer of stroma
Viral
Most common – usually caused by adenovirus (after URTI)
Watery tearing, occasionally mucous discharge.
Follicles on palpebral conjunctiva
Preauricular lymph nodes, submandibular lymph nodes
Bacterial
Mucopurulent discharge
Matting of eyelashes, difficulty opening eyes in the morning,
crusts on eyelashes
Papillae on palpebral conjunctiva
Staph, Strep, Haemophilus, Chlamydial, Gonoccocal
Allergic
Red/pinkish eyes, follicles
Watery discharge, chemosis
History: allergic rhinitis, asthma
Management
Viral
Supportive
Antibiotic drops
Bacterial
Fluoroquinolones
Aminoglycosides
1 drop 4-6 times daily
Frequent hand hygiene
Allergic
Antihistamines
Cold compress
Case: 36/M
CC: eye redness and discharge
HPI: 3 days history of eye redness, with whitish-yellowish
discharge. Difficulty opening eyes due to matting of eyelashes. No
photophobia.
PE:
VA:
OD OS
SC 20/50 | J1 20/30 | J1
PH 20/20 20/20
CC No corrective lenses No corrective lenses
Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, lens,
EOMs
Fundoscopy: +ROR, clear media, distinct disc margins, AV 2:3,
CD 0.3
SUBCONJUNCTIVAL HEMORRHAGE
Bleeding under the conjunctiva
Generally benign
- Spontaneous
- Coughing, sneezing, bending over, vomiting, valsalva
maneuver, lifting heavy objects
- Trauma or surgery
- Recurrent arteriosclerosis (elderly)
- Impaired coagulation (hemophilia, aspirin)
Treatment
Assurance
Supportive
Artificial tears
Cold compress then warm after.
PTERYGIUM vs. PINGUECULA
Pterygium
Wing-shaped, triangular growth of tissue that extends from
the conjunctiva the cornea, usually on the nasal side
Fibrovascular; almost always preceded by pinguecula
Pigmented iron line at the anterior edge of the pterygium
(Stocker line)
Pinguecula
Same, but NOT reaching the cornea.
Yellowish nodule temporal/nasal to the cornea
Symptoms/Signs
Pugita (pterygium), foreign body sensation, redness, itching,
tearing
Cause: Sun, Sand, Wind
Elastotic degeneration (actinic damage from UV)
Treatment:
Pterygium: excision with conjunctival autograft – reduces
recurrence rate to 6-5% (vs. 24-89% - bare sclera); alternative
amniotic membrane graft
Pinguecula: lubricants, weak steroids (pingueculitis)
Case: 35/M
CC: eye redness and yellow-whitish bumps on the nasal side of the
conjunctiva
HPI: 1 week history of eye redness, spontaneously resolves, no
discharge. Foreign body sensation.
PE:
VA:
OD OS
SC 20/20 | J1 20/20 | J1
PH
CC No corrective lenses No corrective lenses
Lids, lashes, conjunctiva, sclera, cornea, AC, iris, pupils, lens,
EOMs
Fundoscopy: +ROR, clear media, distinct disc margins, AV 2:3,
CD 0.3
HORDEOLUM
EXTERNAL vs. INTERNAL
Infection of Zeis and Moll (Stye)
Infection of Meibomian gland
Symptoms: pain, erythema, swelling
Causes:
Staph infection
Treatment:
Warm compress 10-15 mins, TID-QID
If no resolution in 48 hours – I&D
Internal – vertical incision
External – horizontal incision
Antibiotics – ointment; oral; Co-amox BID if with preseptal cellulitis
CHALAZION
Idiopathic, sterile, chronic granulomatous inflammation of
meibomian gland
Painless swelling
Biopsy indicated for recurrent chalazion; meibomian gland
carcinoma mimics the appearance of chalazion
I&C; vertical incision (conjunctival surface), horizontal (skin
surface)
Visual Acuity
angular measurement of testing distance to the minimal object size
resolvable at that distance
Vital sign of the eyes
20 – testing distance
50 – distance at which a normal/unimpaired eye can see that
line
Near vision – Jaeger notation
Test Targets
Optotypes – individual letter/number or picture on a testing
chart
B – hardest for patients to recognize, misinterpreted as E or 8
C, D, O
L – easiest
References/Sources
http://www.visionaware.org/info/your-eye-condition/guide-to-
eye-conditions/refractive-error-and-astigmatism/125
http://www.allaboutvision.com/eye-exam/refraction.htm
American Academy of Ophthalmology
Kanski
Vaughan and Asburys
GOODLUCK!
