History talking:
- Confirm the patient’s identity
- Start the station well (I can see from my notes that you are here as you are having…)
- IPS:
– Pick up on non-verbal cues (if the patient is leaning forward, partially closing his eye or covering his eye)
– Build Rapport. - P1
– Explore the main complaint: Vision problem
– Which eye?
– What about the other ear?
– Are you able to see at all? - Exclude other D.Ds:
– Trauma, Fever, Discharge, Neurological symptoms (Stroke/ TIA), foreign body, Itching, watering.
– Use of spectacles and contact lenses. - Exclude Contraindications of the mydriatic drops for Fundoscopy:
– Acute Angle Closure Glaucoma - P2 (start with an open question, then specify)
– Medical Conditions (specify blood pressure, blood sugar).
– Medications.
– Allergies (ask about any allergy to medications in particular)
Examination
- Vitals
- GPE
- Eye examination: (Including Visual Acuity, Visual Field, Pupillary light reflex, accommodation reflex,
red reflex and Fundoscopy)
Patient preparation:
Patient: Explanation – Benefit – Risk
- I would like to examine your eyes now , for the purpose of examination, I will be looking at your eyes, i will be using a device called opthalmoscope that has a light to visualise the back of your eyes. In order for me to do that i will be putting eye drops for you that will dilate your pupils to gain a better vision of the back of your eyes.
- These eye drops will make your vision blurry for about 4 to 6 hours, so please do not drive and do not sign any important documents.
Doctor
- Position: sitting
- Exposure : the patient has to remove his glasses and/or contact lenses
Both
- I will have a chaperone with me during examination and I will be ensuring your privacy. Am I clear to you? , do you have any questions?, Do I have your consent to proceed?
Examination Steps
- Go to the mannequin only after taking the consent.
- Check if the Ophthalmoscope is working.
- Check power of lens.
- Check light (Half-moon/ full moon)
- Verbalize that ideally you should be examining both eyes , but for the purpose of examination , we will examine the affected eye.
Inspection:
- Symmetry - Redness – Swelling – Abnormal tearing – Discharge.
– Ptosis
– Exophthalmos (front – sides – back) - Check for nystagmus
– Ask the patient to sit still and fix his head.
– Ask the patient to follow your finger only with his eyes without moving his Head.
– Draw + with your finger and observe any nystagmus.
Reflexes:
Red Reflex (Dark room)
- Verbalize: Ideally, I should Switch off the light, but for the purpose of the examination I’ll do this examination with the light on.
- Be away from the patient of about one arm (not too close and not too far).
- Direct light source (fundoscopy or torch) to one eye.
- Do the same with the other eye.
- Light should be reflexed on eye giving red color (this means the eye media is clear).
Pupillary Reflex
- (Indirect – Direct – Consensual → on one go)
- Tell the patient first:
- This is a source of light, I will be directing it at your eyes and looking at your eyes, would that be ok with you?
- Could you please, put your hand at your nose bridge to be as a barrier between your eyes?
- Then, Put the light source at one eye and see if the pupil constricts in this eye (direct) and see if pupil of the other eye which is not exposed to light (indirect).
- Do the same with the other eye.
- Swings the light source between 2 eyes and observe pupil constriction (Consensual)
Accommodation Reflex:
• Patient will be sitting on a chair.
• Most important point → tell the patient:
- Please, look at the wall and choose any point on the wall and focus your looking
on it. - Then, I ‘ll bring my finger abruptly in front of your vision, please once I bring my
finger, look at it without moving your head.- Observe for pupil accommodation.
Visual Acuity
One eye is covered
Snellen chart Or Finger counting.
- Snellen Chart can come either on paper or board.
- If it comes on paper, do not bring it too close. If no chart in the cubicle → Do finger counting with same steps.
- Verbalize → Ideally. I should be at a distance of 6meters.
- Check each eye separately.
- Instructions:
– To check left eye → Please, cover your right eye with your right hand.
– To check right eye → Please, cover your left eye with your left hand.
– Tell the patient → Which line does you see clearly? (Do not ask about each line individually to save your time).
– Start from the line which the patient sees clearly.
Ishihara chart (Colour vision)
- Would not be there
- Verbalize → Ideally, I should check color vision using Ishihara chart.
Visual Field
Peripheral (White pin)
- Eye is covered (with glasses)
- Examine each eye separate.
- Patient is sitting in front of you.
- Tell the patient:
– I’ll be examining your field ofvision of your right eye, so,could you please, cover your left eye with your left hand.
– Thank you, I ‘ll do the same for me (both you and patient cover the same side).
– Do not move your head and when you see the pin, please, let me know. - Use the white pen to draw a full (x) shape for each eye.
- Each eye has 2 sides:
– Temporal (above and below).
– Nasal (above and below).
– Draw full (x) with a half of (x) on each side temporal (above and below) and nasal (above and below).
Central (Red pin)
- Eye is covered (with glasses)
- Examine each eye separate.
- In central field test we are looking for blind spot.
- It is a spot where patient cannot see.