Psych/Eye

• 1 Eye Terminology

• 2 Ocular history

• 3 Ocular physical exam

• 4 Ocular imaging

• 5 Common eye diseases

Preparing for your Ophthalmology rotation

CDR Amy L. Barrion, M.D.

Welcome to the whole new world of ophthalmology! This introduction includes helpful tools to successfully begin your ophthalmology rotation. This overview consists of basic ophthalmologic terminology, ocular history and physical exam and common eye diseases. We will expand on this information during your rotation. This is comprehensive go-by for you to review and can serve as a future reference for you to further your skills in ophthalmology if you would like. We look forward to working with you.

Eye Terminology

First, you will need to learn a new language! As you will soon discover, ophthalmologists use several abbreviations and terminology unique to this field. To decode all of those abbreviations, here is a link to an ophtho translator (https://eyeguru.org/translator/). You can type in individual terms or copy/paste entire notes to start learning. Also included is the most comprehensive online list of common ophthalmology abbreviations.

Ocular history

We will highlight questions you should ask targeting specific eye concerns in addition to the regular routine medical history taking.

History of Present Illness (HPI):

Start by obtaining their chief complaint, then continue to target specific concerns regarding the patient’s eyes as needed. Ask about 5 categories: vision changes, ocular pain, abnormal ocular secretions, abnormal appearance, and trauma.

1. Vision changes

   • Blurred vision (peripheral or central vision)

   • Diplopia (monocular, binocular, horizontal, vertical, and oblique)

     • Tip: Make sure to ask if the double vision is monocular (present with one eye open) or binocular (present only if both eyes are open).

   • Floaters (moving lines or specks in the field of vision)

   • Photopsias (flashing lights)

   • Shadow or dark curtain in vision

   • Halos or rainbows

   • Color vision abnormalities

   • Blindness (ocular, cortical, perceptual)

2. Ocular discomfort or pain

   • Foreign-body sensation (a feeling of scratchiness)

   • Dry eyes

   • Photophobia (light sensitivity)

   • Headache

   • Burning

   • Itching

3. Abnormal ocular secretions

   • Discharge (purulent or watery)

   • Lacrimation (tearing) or epiphora (spilling of tears over the margin of the eyelid into the face)

4. Abnormal appearance

   • Redness

   • Misalignment of eyes

   • Ptosis (dropping eyelid)

   • Proptosis (protrusion of eye from socket)

   • Anisocoria (unequal pupil size)

5. Trauma

   • Type of collision

   • Any perceived foreign body into the eye

   • Chemical spill

Past Ocular History (POhx)

• Use of eyeglasses or contact lenses (date of most recent prescription)

• Ocular surgery (including laser)

• Ocular trauma

• History of amblyopia (lazy eye) or ocular patching in childhood

Ocular Medications (Gtts)

There are three important things to record when it comes to ocular medications (the type, the frequency, and the laterality—right eye or left eye). You will soon discover that the knowing the color of the eye drop type will be crucial as many patients know their medication by color instead of name.

• Here is an eye drop color chart cheat sheet: https://eyeguru.org/blog/eye-drop-colors/.

Other important medical history

Remember that the eye is connected to the rest of the body, so don’t forget all the important parts of a routine medical history!

• Past medical/surgical history

  • Ocular findings can be a manifestation or association with systemic diseases.

    • Ie Always ask about a history of diabetes mellitus and hypertension

• Systemic medications

  • Specific medications can lead to ocular toxicity

    • Ie. Hydroxychloroquine

  • Allergies

    • Ask for any adverse effects to eye drops.

    • Environmental atopy (can be a clue to allergic/vernal conjunctivitis).

  • Social history

    • Tobacco, alcohol use, drug abuse, and sexual history will be important to record. Smoking is a risk factor for age-related macular degeneration. Many sexually transmitted diseases can have ocular manifestations such as uveitis and acute retinal necrosis.

  • Family history

  • Review of systems

Ocular physical exam

Ophthalmic vitals (Visual Acuity, Intraocular Pressure, and Pupils)

1. Visual Acuity (VA)

   • Obtain the best corrected visual acuity (BCVA). Make sure they are wearing their prescription glasses/contacts when you check this!

   • Give the patient credit for any line in which they get 50% or more of the letters correct. If they miss less than 50% of the letters on that line, you can indicate that by writing “-“ and the number of letters they missed

     • Example: Patient gets 3 letters correct on the 20/30 line, which contains 6 letters: BCVA 20/30 – 3

   • Pinhole (ph) Acuity Test (helpful if patients forget their prescription glasses)

     • If the patient’s visual acuity improves by 2 lines or more with pinhole, it is likely the patient has refractive error. This is because the pinhole admits only central rays of light, which do not require refraction by the cornea or the lens.

   • Note: In the clinic, visual acuity is typically measured at distance. Otherwise, in a consult setting outside of the clinic, it’s often easier to measure at near. Keep in mind near vision may be affected by presbyopia.

   •         Keep a near card in your white coat pocket.

2. Intraocular pressure (IOP)

   • Tonometry is a measure of intraocular pressure (Normal IOP: 10-21 mmHg). There are three ways to measure IOP:

     • Non-contact tonometry (usually an air puff)

     • Tono-pen (hand held)

     • Goldman applanation using the slit lamp.

       • Applanation is the most challenging method. It will take practice! Here is a step-by-step guide to master this technique: https://eyeguru.org/essentials/slit-lamp-tips/#6_Checking_intraocular_pressure_by_applanation.

3. Pupils

   • There are five important things to consider when examining the pupils: size, shape, position, symmetry, and color. For a detailed overview on performing the pupil exam: https://eyeguru.org/blog/examining-the-pupil/.

External examination

• Extraocular motility (EOM) and alignment

  • Check for gross alignment in primary position (straight ahead). There are technically six cardinal positions of eye movement. All six can be evaluated in each eye by having the patient follow your finger as you draw a capital “H” in front of them.

• Confrontational Visual Field (VF) Testing

  • There are several unique ways ophthalmologists test for visual fields. We will go over this during the rotation.

  • Diagraming the VFs is unique because you plot the abnormality as the patient sees it.

• The slit lamp is the core instrument of ophthalmology and using it takes practice. We’ve collected the most high yield tips to get you examining like a pro. These are the hard things that all beginners struggle with: https://eyeguru.org/essentials/slit-lamp-tips/

• Here is the list of anterior segment structures that can be visualized using a slit lamp:

Dilated Fundus Examination (DFE)

The fundus, the retina, the back of the eye are all words that are used interchangeably by ophthalmologists. There are two ways to visualize the posterior segment of the eye:

• Using the slit lamp with a 90D or similar small lens. Click this link for our technique guide: https://eyeguru.org/essentials/slit-lamp-tips/#2_The_dilated_retinal_exam

• Using the indirect ophthalmoscope with a 20D or similar large lens. Click this link for our technique guide: https://eyeguru.org/essentials/indirect-ophthalmoscope-tips/

Here is the list of posterior segment structures that can be visualized using the techniques above with some things you should be looking for:

• • Vitreous: Clear? Has haze/cells? Vitreous hemorrhage?

  • Optic Disc nerve: Cup-to-disc ratio? Focal thinning? Pallor? Symmetric?

  • Macula: Foveal light reflex? Drusen, edema or exudates?

  • Vasculature: Contour and size? Intraretinal hemorrhage? Attenuated? Sheathing?

  • Periphery: Tears or holes? Lesions? Pigmentary changes?

Ocular imaging

There are several unique imaging modalities that are used daily in ophthalmology. We will outline each of them here:

• Color fundus photo or optos photos

  • A true color fundus photo is essentially a normal photo of the back of the eye. An optos camera/optomap will yield an image captured by a special scanning laser that looks similar but will have a wider field of view and will usually be green-tinted. Your clinic may have one or both of these types of imaging.

  • Master your skills using our fundus practice module: https://eyeguru.org/practice/fundus/.

• Optical coherence tomography (OCT)

  • A non-contact, high-resolution, in vivo imaging modality that produces cross-sectional images of the retina. Allows you to see all retinal layers.

  • Learn how to read OCT images: https://eyeguru.org/essentials/interpreting-octs/.

  • Master your skills using our OCT practice modules: https://eyeguru.org/practice/oct-beginner/.

• Fluorescein Angiography

  • A type of retinal imaging that is paired with IV dye injection to evaluate blood flow to the retina and choroid.

  • Learn how to interpret fluorescein angiography: https://eyeguru.org/essentials/fluorescein-angiography/.

• Humphrey visual field

  • An imaging modality used to evaluate a patient’s visual fields – much better (and quantifiable) compared to confrontational visual fields done on physical exam.

  • Learn how to interpret visual fields: https://eyeguru.org/essentials/visual-fields/.

• Ocular ultrasound (B-scan)

  • An ultrasound of the eye used for evaluating the eye for retinal detachments, masses or hemorrhage in the vitreous, and intraocular tumors.

  • Learn how to interpret B-scans: https://eyeguru.org/essentials/ophthalmic-ultrasound/.

• Corneal topography (Pentacam)

  • Like topographies on standard land maps, corneal topography gives you information on the elevation pattern on the front of the cornea. Newer types give you thickness and posterior corneal surface information as well.

  • Learn how to interpret corneal topography: https://eyeguru.org/essentials/corneal-topography/.

Common eye diseases

The bread and butter of ophthalmology includes the following diseases: cataracts, dry eye syndrome, corneal abrasions and ulcers, age-related macular degeneration, diabetic retinopathy, and uveitis.

For more advanced information, the pathology frameworks in the residency essentials section covers the basics of how to diagnose and manage these diseases: https://eyeguru.org/residency-essentials/.