WEBVTT

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*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.*

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This videotape demonstrates a series of basic

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techniques for ocular examination and management.

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The techniques have been taken from the following series of

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self instructional slide tape units.

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Since this videotape is intended to supplement the

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slide tape units.

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We recommend that you study them first,

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then view the videotape to refine your

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techniques or to answer questions about a particular

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technique.

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The videotape is meant primarily to demonstrate

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performance the slide tape units

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present examples of normal and abnormal patients

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and go into more detail about indications

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background knowledge and conditions for referral.

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The techniques presented our confrontation

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visual field testing,

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corneal examination,

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examination of the pupil,

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checking the anterior chamber,

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depth

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motility,

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basic screening

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installation of eye drops,
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version,
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patching

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superficial foreign body

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removal,
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irrigation

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and ocular massager.

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When a patient complains of blind spots,

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bumping into things or other symptoms

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suggestive of a visual field defect.

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A confrontation visual field test should be

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performed.

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It is also an important part of a complete neurologic

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examination

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confrontation.

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Visual field testing can only rule out gross

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visual field defects.

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Each eye is tested separately.

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The visual field is divided into quadrants with the

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center at the point of fixation.

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First each of the quadrants is tested

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separately

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to detect more subtle defects.

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The left and right quadrants are tested

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simultaneously.

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Finally the nasal and temporal

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halves of the visual field are compared for

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their relative clarity

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in this procedure,

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the patient's visual field is compared with the examiners,

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The patient and examiners should be seated facing each other

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about one m apart.

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The patient should cover one eye and the examiner

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should close his own opposite I the

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patient should maintain fixation on the examiners

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open eyes in a plane

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midway between patient and examiner,

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the examiner presents his closed hands in

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each of the upper quadrants of his own visual field,

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so that he can clearly see one hand in each of his

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own upper quadrants.

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To test the upper nasal and temporal quadrants.

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The examiner should display 12 or

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five fingers on one hand,

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then on the other hand ask the patient how many

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fingers are seen randomly alternate

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hands.

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Two,

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one,

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two,

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two.

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Next 1.

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The examiner shows fingers of both hands

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simultaneously and ask the patient how many

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total fingers are shown?

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Four,

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two,

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four.

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This so called double simultaneous

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presentation may identify a subtle field

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defect that wasn't evident when testing the

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individual quadrants.

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Similarly the lower temporal and nasal

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quadrants are tested singly one,

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one and simultaneously

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two.

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Be sure that the patient maintains fixation on your open

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eye and keeps the other I completely covered.

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You should be able to count your own fingers at all times.

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Any difficulty in counting fingers suggests a

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visual field defect.

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Finally,

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with the patients I still covered the examiner

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presents the palms of both hands,

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left and right of center and the patient is asked

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if both hands are equally clear both hands

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equally clear

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blueness of any part of one hand compared to the

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other suggests the defect.

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Next the opposite.

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I is tested.

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Have the patient cover the other eye and repeat the

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procedure.

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First the upper quadrants are tested singly.

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Okay,

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one and

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simultaneously two.

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Then the lower quadrants are tested

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when two.

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One true,

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two.

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Two.

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Finally have the patient compare the palms for

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clarity,

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arms equally clear.

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Yes,

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the results of your testing should be described or

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sketched,

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since this is only a gross test by

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confrontation should be included in the

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patient's record.

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A defect demonstrated by the confrontation

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method requires referral for more

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precise visual field testing.

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There are four tests used to examine the Cornea,

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corneal clarity,

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corneal light reflection,

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fluorescent staining and corneal

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sensitivity

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as the window of the eye.

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The cornea must be perfectly clear.

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You should be able to see the irish details clearly

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as your pen light illuminates the eye

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haziness of irish details may indicate that the

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cornea is not entirely clear.

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The cornea should not only be clear,

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but its surface must also be perfectly smooth.

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This is most easily checked by examining the

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corneal light reflection.

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A good light source should be large,

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such as a fluorescent fixture or a window.

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A normal corneal surface reflects the light source

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clearly and sharply mirror like as

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demonstrated with this mirror

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and on an actual cornea,

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as seen here,

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any distortion of the reflected image suggests an

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irregularity of the corneal surface.

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A window or a fluorescent fixture is a good

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light source because any distortion of a large

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rectangular image is detected much more

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easily than distortion of a small source,

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such as your pen.

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Light with the patient

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seated opposite the light source

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tilt the patient's head is needed

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so that the reflection is clearly visible on the

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patient's cornea.

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Then have the patient's eyes follow your finger

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so that the reflection moves systematically

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over all parts of the cornea in

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succession

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by having the patient follow your finger up,

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down,

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left and right.

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The entire cornea can be systematically scanned for

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irregularities.

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Common causes of an irregular surface are

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abrasion,

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foreign body corneal ulcer or

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corneal scar.

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If a defect in the corneal surface is suspected

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from the history or from your examination,

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fluorescent staining should be performed.

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Floor scene will stain any area of the cornea

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where the epithelium has been disturbed.

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It is used to confirm suspected interruptions of the

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corneal epithelium and to detect subtle

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defects which might not be found in any other

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way.

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You will need some sterile floor seen strips

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in a squeeze bottle of sterile irrigating solution,

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remove a floor seen strip,

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taking care not to contaminate it.

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Place a drop of sterile irrigating solution on the

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tip,

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Retract the eyelids gently and instruct the

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patient to look down or up

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briefly touched the floor seen.

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Strip to the con Gentiva,

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above or below the cornea.

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Do not touch the cornea as an abrasion could

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result,

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have the patient blink a few times so that the flow racine

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is spread over the cornea

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flush out any excess floor scene with some

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drops of sterile irrigating solution,

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Check the cornea for any areas where the dye is

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retained.

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Any green staining that adheres to the cornea

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denotes an area of damaged epithelium

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Corneal sensitivity testing is indicated

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when you wish to test the integrity of the 5th

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cranial nerve or to determine

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if a herpes simplex infection has

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compromised the superficial nerve endings.

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If indicated,

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corneal sensitivity should be checked after fluorescent

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staining since the sensitivity test may

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cause an ia tra genetically positive fluorescent

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stain.

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The examiner first teases out some strands from a

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cotton swab.

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Then the patients should be instructed to look to the side

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opposite the eye.

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Being tested,

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the examiner retracts the eyelids

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and brings the swab in laterally.

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To avoid a visually evoked blink response.

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Then the peripheral cornea is lightly touched with the teased

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out strands.

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When normal sensation is present,

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a light touch applied to the cornea evokes a blink

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reflex and slight discomfort.

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Repeat the test on the other eye.

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Using a new cotton swab to avoid any

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possibility of cross contamination.

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You should ask the patient if the touch felt the same in each

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eye.

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Reviewing the four tests used to examine the Cornea

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first make sure the cornea is perfectly

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clear and that the irish details are easily

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seen.

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Then check the surface of the cornea.

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Using a large,

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rectangular light source

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fluorescent staining will confirm suspected

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interruptions of the corneal epithelium.

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Finally,

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to check the integrity of the fifth cranial nerve or

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to determine if a herpes simplex infection has

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compromised the superficial nerve endings,

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corneal sensitivity is tested.

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When examining the pupils,

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you should check them for shape,

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size and reaction to light

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pupils should be tested in a semi dark room,

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since inequality has become more obvious when the pupils are

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wide instruct the patient to look

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at an object at least 10 ft away to prevent

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the constriction of the pupil due to the near reflex,

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the pupil should be round and in the center of the

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iris.

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The pupil should be approximately equal in diameter.

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A difference in diameter of greater than one millimeter

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may indicate a significant abnormality.

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To check the pupils reaction to light first

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illicit the direct pupil.

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Every reaction

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Shine your penlight into one I the

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pupil of this I should constrict quickly and

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smoothly

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Shining a light into one pupil should also

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bring about symmetrical constriction of the opposite pupil.

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This is the consensual pupil.

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Every reaction

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as you shine your hand light into one,

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I observe the pupil of the other eye for

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consensual constriction.

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Similarly observe the direct and consensual

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pupil very reactions with the light shining in the

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other eye,

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analyzing the direct and consensual reactions

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will help you determine if there is a defect of the different

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sensory pathways.

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Notice that the pupils are unequal here and the

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left pupil of this patient does not react to a light

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stimulus shone directly into it,

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nor does it react consensually.

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The swinging flashlight test is a sensitive screening

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method for detecting defects in the different

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sensory pathways.

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The test is based on the fact that an eye with a

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defect of the different sensory pathway

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effectively receives a weaker stimulus

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and thus has a weaker pupil eri response than a

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normal I.

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When the hand light shines into the normal I.

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A normal direct and consensual

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response is seen

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when the flashlight swings quickly to the abnormal

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I.

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The direct reaction is less than the previous consensual

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reaction and thus a

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paradoxical dilatation occurs

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since the stimulus to this I is not adequately

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transmitted centrally.

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The direct and consensual reactions are decreased

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or may even be absent.

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When the light is quickly swung back to the normal I

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breast constriction is seen again.

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This patient has an abnormality of the optic nerve.

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Watch as the swinging flashlight test is

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demonstrated,

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swing your light back and forth quickly several times

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to make sure that the response is consistent and

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that you did not miss a subtle difference.

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It is crucial that the light be swung very quickly between

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the two eyes in order to avoid the normal

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dilation from the relatively low level of

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ambient illumination.

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The paradoxical debilitation is called a

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Marcus Gunn pupil

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while you are using your hand light to check the pupil,

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you can also use it to check the depth of the anterior

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chamber.

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This is an important screening test for possible narrow

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angle glaucoma.

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The anterior chamber is the space between the

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cornea and the iris.

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In a shallow chamber the iris bulges

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forward,

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interrupting a light beam shining across the iris

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and causing a shadow to fall over the part of the iris

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away from the penlight.

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In a normal chamber,

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the beam will shine across the entire iris

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to check the chamber depth,

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shine your pen light from the side of the eye.

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Normally,

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the light illuminates the entire iris.

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As shown here

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in a narrow chamber,

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a shadow falls on the nasal side of the iris.

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As shown here in patients with a

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shallow chamber dilating,

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the pupil may cause a chamber angle block,

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triggering an attack of acute glaucoma.

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These patients should not be dilated and should be

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referred to an ophthalmologist for appropriate

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care.

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Yeah.

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In the evaluation of extra ocular muscle function

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there are four aspects range of motion

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smoothness of motion,

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stability,

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an alignment of the eyes

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to test the patients range of motion.

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Have the patient follow your finger into the

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six cardinal positions of gays.

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You should note whether there is any limitation in the ability

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of one or both eyes to move into the various

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positions

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when in doubt about whether one eye is limited in movement,

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compare its range of movement to that of the other

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eye.

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A limitation of movement of one eye.

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As demonstrated here may indicate either

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a mechanical constraint or a

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paralysis.

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When both eyes cannot move to a given direction

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it indicates a gaze palsy of super

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nuclear origin.

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In all cases the patient should be referred for

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ophthalmological evaluation

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while the patient is following your finger.

22:05.640 --> 22:07.860
Also note the smoothness of motion

22:08.760 --> 22:10.900
and the ability to hold the eyes still.

22:11.240 --> 22:13.460
As the patient fixates on your finger,

22:15.020 --> 22:17.520
inability to hold the eyes still is known as

22:17.520 --> 22:18.380
nystagmus.

22:19.580 --> 22:22.320
Nystagmus may remain the same in all positions of

22:22.320 --> 22:25.100
gays or maybe more pronounced in some

22:25.100 --> 22:27.420
positions and absent in others.

22:28.230 --> 22:30.770
Such differences should be noted if present,

22:33.530 --> 22:36.330
notice the jerk nystagmus evidenced by this

22:36.330 --> 22:36.950
patient

22:47.040 --> 22:48.770
and the pendulum nystagmus

22:49.440 --> 22:51.170
demonstrated by this patient.

22:52.440 --> 22:55.370
Any patient with nystagmus who has not been evaluated

22:55.370 --> 22:57.670
previously should also be referred.

23:01.740 --> 23:02.360
Finally,

23:02.920 --> 23:04.710
check the alignment of the eyes.

23:05.740 --> 23:08.610
Patient complaints of diplo pia or double

23:08.610 --> 23:11.390
vision often originate from defects in the alignment

23:11.390 --> 23:12.760
mechanism of the eyes.

23:14.420 --> 23:17.300
You can determine if the eyes are straight or binocular

23:17.300 --> 23:19.970
early aligned by noting the relative

23:19.970 --> 23:22.170
position of the corneal light reflections

23:23.480 --> 23:25.900
as the patient fixates on a light source.

23:26.270 --> 23:29.190
The corneal reflection should be positioned over the center

23:29.190 --> 23:30.380
of the two pupils.

23:31.720 --> 23:32.650
In this patient.

23:33.010 --> 23:35.690
The corneal reflection of the left eye is not in the

23:35.690 --> 23:38.680
center of the pupil If

23:38.680 --> 23:40.800
you suspect deviation of one I.

23:41.180 --> 23:43.270
A cover test should be performed.

23:44.240 --> 23:46.550
Have the patient stare at a distant object

23:47.640 --> 23:50.500
with your hand Cover one eye and

23:50.500 --> 23:52.520
watch for any movement of the other eye

23:53.440 --> 23:55.360
repeat this with the other eye.

23:56.740 --> 23:59.410
Since both eyes are aligned on the same target

23:59.940 --> 24:02.510
covering either I should normally not

24:02.510 --> 24:03.960
result in any movement.

24:05.230 --> 24:07.800
If one eye is not aligned with the fixation

24:07.800 --> 24:08.350
target,

24:08.940 --> 24:11.850
then covering the I will cause the nonaligned

24:11.850 --> 24:14.550
I to move to take up fixation.

24:15.620 --> 24:18.260
You see in this patient that covering the normal I

24:18.500 --> 24:19.650
resulted in movement.

24:19.950 --> 24:22.730
Since only the normal I was already fixating on the

24:22.730 --> 24:23.250
target.

24:25.000 --> 24:27.650
Testing for alignment of the eyes is particularly

24:27.650 --> 24:29.300
important in young patients,

24:29.800 --> 24:32.540
since an untreated deviation may lead to lifelong

24:32.540 --> 24:33.360
amblyopia,

24:53.740 --> 24:54.360
mm hmm.

24:57.380 --> 25:00.250
Several ophthalmological examining techniques have been

25:00.250 --> 25:02.540
demonstrated confrontation,

25:02.540 --> 25:05.540
visual field testing anterior chamber,

25:05.540 --> 25:07.910
depth check examination of the

25:07.910 --> 25:09.600
pupil corneal,

25:09.600 --> 25:09.840
light,

25:09.840 --> 25:10.790
reflection,

25:10.800 --> 25:12.560
corneal sensitivity,

25:13.140 --> 25:15.330
corneal clarity and

25:15.330 --> 25:16.500
motility.

25:16.540 --> 25:19.310
Some of these techniques need only be performed as

25:19.310 --> 25:20.060
indicated.

25:20.540 --> 25:23.540
Others are important to use on every patient

25:23.550 --> 25:25.250
as part of your routine physical

25:25.250 --> 25:26.590
examination.

25:26.600 --> 25:29.410
Such a basic screening takes little time

25:29.420 --> 25:32.420
and will now be demonstrated in patients

25:32.420 --> 25:34.030
without ocular complaints.

25:34.040 --> 25:36.800
This screening should detect most latent eye

25:36.800 --> 25:38.030
problems.

25:42.730 --> 25:45.150
There are four basic ocular history screening

25:45.150 --> 25:45.910
questions.

25:46.640 --> 25:48.940
Ask the patient whether her vision has ever been

25:48.940 --> 25:51.940
decreased and also whether it is the

25:51.940 --> 25:53.440
same in both eyes.

25:54.600 --> 25:56.670
Then ask whether the eyes have been red,

25:56.870 --> 25:58.950
painful or otherwise bothersome.

25:59.940 --> 26:00.630
Finally,

26:01.040 --> 26:03.920
ask whether a doctor or anyone else has ever

26:03.920 --> 26:06.560
told the patient that there was anything abnormal or

26:06.560 --> 26:08.240
unusual about the eyes.

26:09.340 --> 26:12.080
After taking the ocular history begin the

26:12.080 --> 26:12.960
examination,

26:14.240 --> 26:15.050
test your eyes.

26:15.050 --> 26:15.170
Now,

26:15.940 --> 26:18.060
would you cover the left eye

26:18.840 --> 26:21.670
palm of your hand and look down towards

26:21.670 --> 26:24.010
that chart over there and read

26:24.420 --> 26:26.550
the line just under the green line.

26:27.340 --> 26:27.740
Okay.

26:27.970 --> 26:29.060
You see those letters.

26:29.740 --> 26:30.340
T.

26:30.390 --> 26:33.360
P E O L F

26:33.740 --> 26:34.670
DZ.

26:35.040 --> 26:35.360
Good.

26:35.740 --> 26:37.060
Now cover your other eye.

26:37.940 --> 26:38.270
Okay.

26:40.440 --> 26:41.190
Okay.

26:41.940 --> 26:44.800
T P E O L

26:44.810 --> 26:45.340
F.

26:45.350 --> 26:45.740
D.

26:45.740 --> 26:46.170
Z.

26:47.940 --> 26:48.560
Okay.

26:49.120 --> 26:52.090
Now I'm going to look at your eyes to

26:52.090 --> 26:52.770
look over there,

27:03.640 --> 27:04.170
look up.

27:08.940 --> 27:09.170
Okay,

27:33.040 --> 27:33.970
fine.

27:34.290 --> 27:35.420
Now look at my finger.

27:41.840 --> 27:44.640
This patient's eyes fixate and moves smoothly

27:44.650 --> 27:47.220
over the full range of motion and they are well

27:47.220 --> 27:47.860
aligned.

27:49.340 --> 27:52.060
The next step is op Tomasz Capi

27:56.640 --> 27:57.430
1 2nd.

27:57.620 --> 27:58.780
I'll turn off the lights.

28:03.440 --> 28:05.330
I'm going to look inside your eye now.

28:05.340 --> 28:08.150
I'd like you to look right at that door knob across the way.

28:08.370 --> 28:10.460
Try not to look directly at my life.

28:33.740 --> 28:34.060
Mhm.

28:34.440 --> 28:35.860
I'm going to look in your other eye.

28:35.860 --> 28:37.050
Look over my other shoulder.

28:38.240 --> 28:38.770
Same place

29:02.440 --> 29:03.670
your eyes look fine.

29:06.740 --> 29:09.520
The last thing I'm gonna do is check the pressure inside your

29:09.520 --> 29:09.890
eye.

29:11.640 --> 29:12.860
Would you lie down please?

29:13.340 --> 29:13.550
Thank you.

29:18.340 --> 29:20.740
Has anybody in your family had glaucoma?

29:20.960 --> 29:21.730
Not that I know of.

29:22.000 --> 29:24.200
Have you ever had the pressure in your eyes checked?

29:25.940 --> 29:28.550
I'm going to put some numbing drops in your eyes right now.

29:28.940 --> 29:29.170
Mhm.

29:29.940 --> 29:31.460
So you won't feel the instrument.

29:32.260 --> 29:32.980
Look up for me.

29:32.990 --> 29:35.990
Please Try not to rub or press on your eyes for

29:35.990 --> 29:37.300
the next 15 minutes.

29:37.840 --> 29:39.270
Otherwise you might scratch them.

29:40.740 --> 29:41.060
Mhm.

29:42.960 --> 29:44.270
Here's a tissue for you.

29:48.640 --> 29:51.620
I want you to take your thumb and hold it up over your head over

29:51.620 --> 29:52.060
here.

29:52.940 --> 29:53.500
That's good.

29:53.510 --> 29:55.360
Just keep looking right at the thumb.

29:55.840 --> 29:57.910
Try to pay no attention to this instrument.

29:57.910 --> 29:59.620
Just keep looking right at your car.

29:59.890 --> 30:00.850
That's perfect.

30:01.800 --> 30:03.270
Keep looking at your thumb.

30:08.040 --> 30:09.360
Put your thumb down now.

30:09.740 --> 30:11.960
The pressure in your eyes are perfectly normal.

30:13.630 --> 30:16.570
This patient received a basic but comprehensive

30:16.570 --> 30:19.070
ocular examination in a very short

30:19.080 --> 30:19.660
time.

30:20.430 --> 30:23.140
The technical details of 10 on the tree and up to Mosca

30:23.140 --> 30:23.450
P.

30:23.610 --> 30:26.160
Are covered in the other self instructional units.

30:28.910 --> 30:31.170
If the patient had any ocular complaints

30:31.640 --> 30:34.320
or if you had found any abnormalities in this

30:34.320 --> 30:37.090
screening examination you might have spent more

30:37.090 --> 30:39.820
time exploring the specific findings as

30:39.820 --> 30:41.740
outlined in the tape slide units

31:07.890 --> 31:09.320
to instill eye drops.

31:09.530 --> 31:12.160
The patient should be seated or lying supine.

31:13.320 --> 31:15.780
The patient's head should be tilted back slightly

31:17.340 --> 31:19.950
With a tissue in one hand retract the

31:19.950 --> 31:22.890
patient's upper lid with the

31:22.890 --> 31:25.600
fourth or fifth finger of the other hand which is

31:25.600 --> 31:26.990
also holding the dropper.

31:27.330 --> 31:28.600
Retract the lower lid,

31:30.140 --> 31:31.850
instruct the patient to look up

31:33.040 --> 31:35.850
and instill a drop into the inferior con gente

31:35.850 --> 31:36.550
Vilsack.

31:37.640 --> 31:40.160
Do not place the drop directly onto the cornea

31:42.180 --> 31:44.230
to avoid contact with the lashes.

31:44.740 --> 31:47.510
Hold the bottle high enough so that the normal blink

31:47.510 --> 31:49.890
reflex does not bring the lashes into

31:49.890 --> 31:52.060
contact with the tip of the dropper.

31:54.040 --> 31:56.870
Blot any excess fluid from around the patients.

31:56.870 --> 31:57.270
II