Ophthalmology Level 1 | TheACMSS.org

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Ophthalmology
Continuing Education

ACMSS CONTINUING SCRIBE EDUCATION

Ophthalmologic Specialists

Ophthalmologist:
a physician specializing in
medical and surgical care of
the eye.

Optometrist:
prescribes glasses
and other optical
devices.

Optician:
makes and fits eye
glasses.

How Does the Eye Work?

Much like a camera works …

Basic Eye Anatomy

Anatomy: Eye

The eyeball fits within a
protective bony cavity called
the orbit

The nerve and blood supply
enter the orbit through a
foramen, or hole, in the
bone

Anatomy: “Extraocular muscles”
Control Eye Movements

• Extraocular movements

– Medial (towards the middle)
– Lateral (towards the sides)
– Upward
– Downward

Anatomy: Outer Structures

The Lens of the Eye

Lens: transparent, biconvex, no nerve or pain fibers, no blood vessels, affected in cataract.

Ciliary body: controls accommodation

Iris: colored part, surrounding the pupil.
Pupil: dilates and constricts in response to light.

Cornea: transparent, no blood vessels,
main refracting surface of the eye.

The Eye Examination

Basic Steps of the Eye
Examination – UPDATED

• General physical examination should include:

– Vsual acutiy
– Pupillary reaction
– Extraocular movement
– Direct ophthalmoscope
– Dilated exam (in case of visual loss or retinal pathology)

Basic Steps of the Eye
Examination II – UPDATED

• General physical examination should include:
• Distance or Near
• Distance visual acuity at age 3

– early detection of amblyopia

Basic Steps of the Eye
Examination

• General physical examination should include:

– Vsual acutiy
– Pupillary reaction
– Extraocular movement
– Direct ophthalmoscope
– Dilated exam (in case of visual loss or retinal pathology)

• Distance or Near
• Distance visual acuity at age 3

– early detection of amblyopia

Basic Steps of the Eye
Examination

Snellen eye Chart

Rosenbaum Pocket Chart

What is 20/20 (6/6) vision?

Distance Visual Acuity Testing

• VA – Visual acuity
• OD – Ocular Dexter (right eye)
• OS – Ocular Sinister (left eye)
• OU – Oculus Uterque (both eyes)

• Reporting Visual Acuity (e.g. 20/20)

– Distance between the patient and the eye chart

– Distance at which the letter can be read by a person with normal acuity

Distance Visual Acuity (VA) Testing

• Place patient at 20 ft from the Snellen chart
• OD then OS (right then left eye)
• VA is line in which > 1/2 letters are read
• Pinhole if < 20/20

Near Visual Acuity Testing

• Indicated when

– Patient complains about near vision
– Distance testing difficult/impossible

Pupillary Examination

• Direct penlight into eye wile patient looking at something in the distance

• Terms

– Direct: Constriction of the ipsilateral (same side) eye
– Consensual: Constriction of the contralateral (opposite side) eye

Direct Ophthalmoscopy

• Tropicamide or phenylephrine for dilation

– unless shallow anterior chamber
– unless under neurological evaluation

• Use your own OD to examine OD

– Same for OS

Intraocular Pressure Measurement:
Important for Cataract Diagnosis

• Normal Range: 10 – 22 mmHg

Summary of Steps in Eye Exam

• Visual Acuity
• Pupillary examination
• Visual fields by confrontation
• Extraocular movements
• Inspection of

– Lid and surrounding tissue
– Conjunctiva and sclera
– Cornea and iris

• Tonometry
• Fundus examination

– Disc
– Macula
– Vessels

Chronic Vision Loss

Basics of Chronic Vision Loss

• 1994: 38 million blind people (age > 60 years) worldwide
• 1997: Leading causes of blindness in people over 50 years of age in the West:

1) Macular Degeneration
2) Cataract
3) Glaucoma
4) Diabetic Retinopathy

Glaucoma

• Risk factors:

Old age
African-American race
Family History
High Intraocular Pressure (IOP)

Myopia
Blood Hypertension
Diabetes Mellitus
Smoking

• Classification:

– Open-angle glaucoma vs. angle-closure glaucoma
– Primary vs. secondary

Glaucoma: How does it happen

Blockage of the drainage mechanism of the eyes fluid results in increased pressure.
This pressure “presses” on the Optic Nerve, resulting in damage and visual compromise.

Glaucoma

• Evaluation:

– Complete history
– Complete eye examination
(including IP, gonioscopy, optic disc)

Glaucoma — Updated

• Treatment Options:

– Medical:

– Drops to decrease aqueous secretion or increase aqueous outflow
– Systemic medications (PO or IV) – useful in small percentage of population

– Laser:

– Iridotomy – for narrow angle
– Trabeculoplasty – for open angle

– Surgical:

– Filtration Surgery (e.g. Trabeculectomy)
– Tube shunt
– Microinvasive glaucoma surgery (MIGS)
– Value? surgery

Glaucoma

• Treatment Options:

– Medical:

– Drops to decrease aqueous secretion or increase aqueous outflow
– Systemic medications (PO or IV)

– Laser:

– Iridotomy
– Iridoplasty
– Trabeculoplasty

– Surgical:

– Filtration Surgery (e.g. Trabeculectomy)
– Tube shunt