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Eye Exam / Opthalmoscopy for Medical Student OSCE

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1. Introduce, identify, explain, consent

2. Would test visual acuity, near sight, colour vision (Ishahara plates), visual fields, blind spot, visual neglect, pupillary reflexes, eye movements and double vision

3. Explanation

   1. Pt wear glasses?

   2. Explain procedure

   3. Warns: dark room, have to get close to pt, light may be bright and dazzling

   4. Explain would ideally use eye drops: tropicamide. Possible problems: glaucoma, known allergy, driving motor vehicles / operating machinery

4. Procedure

   1. Inspect exterior part of eye: conjunctiva, iris, vitreous.

      1. Scars

      2. Discharges

      3. Periorbital swelling

      4. Redness

      5. Foreign bodies

      6. Cornea abrasion / ulceration

   2. Instruct pt to blink normally then stare at fixed point

   3. Lens to power 0 and focus on arm

   4. Red reflex

   5. Stabilize head with hand

   6. Right eye to examine right eye

   7. Do not talk during examination

   8. Looking for:

      1. Optic disk (come in from quite laterally) – indistinct margin and raised contour – oedema; neovascularisation due to diabetic retinopathy; pink (normal) / pallor (optic atrophy); cup disk ratio >0.5 – glaucoma; absence of cup – papilloedema

      2. Vessels in 4 quadrants of eye – superior, inferior, temporal, nasal arteries and veins. Microaneurysms, venous beading, arteriolar narrowing, AV nipping, copper/silver wiring, haemorrhages, exudates

      3. All quadrants

      4. Macula – ask pt to look directly into light. Pigmented = senile macular degeneration

      5. Diabetic retinopathy – early signs – microaneurysms, haemorrhages, possibly hard exudates

5. Differential

   1. Diabetic retinopathy – with / without macular involvement:

      1. Non-proliferative (background) – microaneurysms, hard exudates & cotton wool spots, dot & blot haemorrhages, venous beading

      2. Proliferative – the above + formation of new, friable blood vessels. Can bleed ? floaters, ↑intraocular pressure, painful glaucoma

   2. Hypertensive retinopathy – blood vessels thicken and narrow ? ischaemic retinal damage

      1. Grade 1 – minimal arteriolar narrowing

      2. Grade 2 – obvious arteriolar narrowing; AV nipping, silver wiring

      3. Grade 3 – + retinal haemorrhages, hard exudates (retinal star), cotton wool spots

      4. Grade 4 - + papilloedema (malignant hypertension)

   3. Senile macular degeneration – commonest blindness cause in UK >65’s. Disc may appear normal, but macula unusually pigmented

      1. Dry – non-disciform

      2. Wet – disciform – worse prognosis but rarer

   4. Central retinal vein occlusion – stormy sunset appearance of fundus. (Dilated veins, dot and blot haemorrhages, cotton wool spots, papilloedema)

   5. Papilloedema – congestion of optic disc, usually due to ↑ICP. Disc swollen, margin may disappear, with retinal vein congestion.

   6. Optic atrophy – disc pale and grey. Gradual loss of vision. 2? to glaucoma, retinal damage, ischaemia or poisoning

About the Author

by: Admin
Total views: 0
Word Count: 756
Date: Fri, 22 Jan 2010 Time: 4:13 PM
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