The next part of the
exam is the eye exam. And with all exams, of course, you're going
to start with inspection. With inspection of the eye, you look first top to bottom, start with the eye brows, eyelids, look where the
lachrymal glands are. Look at the sclera and
conjunctiva and the pupils, and always, of course,
comparing one eye to the other. Now the next part of this is, I want you to look up
towards the ceiling, and I'm going to just
pull down the lids here, I'm looking at the
lower part of the lids. Good. Again, comparing
sides there. The next part is visual acuity when I'm going to
assess Frank's vision. Now, in your clinical practice, you'll often see your preceptors checking with an eye chart
that's 20 feet away. I'm checking near vision, and that'll be about 14 " away. And for anybody who
needs reading glasses, they should put those
reading glasses on. So Frank, you can put
your reading glasses on because with near vision, you will not be able to see
if he needs reading glasses. Now, Frank, can you hold
this about 14 " away? Now, cover up your
left eye because I'm going to be checking
one eye at a time. And Frank, with your
right eye exposed, look at the lowest line of
numbers that you can read there along the left
side of the chart. 937826. All right. And so
when I look at that, that is 20,25 vision
with the right eye. Now, if you can cover
your right eye, I'll do the same thing
with the left eye and check your vision
again on the left eye. 937826. All right. And same thing so 20,25 vision on both sides. What I'll do now is
assess visual fields. Now, you think about
the visual fields as in four separate quadrants. There's a upper quadrant,
temporal quadrant, lower temporal quadrant, upper nasal and lower nasal quadrant,
that's for each eye. So I'm going to check
each of those quadrants. I'm going to use fingers. I'm going to ask Frank to
tell me whether he's seeing 1,2 or 5 fingers. I'm using those numbers of
fingers because it's easy to distinguish one and two and
five from other digits. Frank, if you can
cover your left eye with your left hand, and what I'm going to do
while he's doing that is I'm covering my
right eye so that I can check my field of vision
against his as a standard. Now, you look at my nose, and then tell me how many
fingers you see me holding up. One. Yes. And just watch
my nose if you can. Now, tell me how many fingers? Two. All right. And how
many fingers here? Five. And you see that I'm
holding it in a way that he's able to see
how many fingers. I'm not going to turn my hand in different directions
where numbers of fingers can be confused. Now, we'll check the same
thing with the other. Keep your hand there, and how many fingers
do you see here? Two. And how many fingers here? Two. All right. Now, you
saw that he didn't see the right number of fingers in the upper outer quadrant so I'm going to
check that again. Now, tell me again how many
fingers you're seeing here. Two. All right. I've checked all four quadrants
of the right eye. Now you can replace that hand and now cover
up your right eye. Now we'll check the left eye. We'll do the same thing,
starting first with the upper and lower
outer quadrants and then switching to the inner
higher and lower quadrants. All right so, again, tell me how many fingers. Five. And how many fingers? One. All right. And here? Two. And here. One. All right. Good. So he's checked all those
quadrants on both sides. Now the next part
of the check here is to check for
the near response. I want to see that
as Frank looks in the distance and then brings his eyes in and
looking towards me, his eyes converge a little, come in closer together, and there's a little bit
of pupilary restriction, but I may not be
able to see that. Now, Frank, if you can look
at the wall over there. And now look at my finger here. And what I see is that his eyes converge and come together. I see a little bit of
pupilary restriction. Now I'll move right into
checking extraocular motions. Just watch my finger here. I'm going to move
this in an H pattern. Out this way and up this way, I'm watching both eyes, making sure that they're both moving in conjunction
with each other. And out this way up
the H pattern up to the top and then down to the bottom and then
back to the center. So that checks all the
extraocular motions of many of the
different eye muscles. The next part that
I'm going to check is watch for pupils to see
that they react to light. Now, typically, for
checking pupils, you want to turn off the light. I'm going to leave
the light on so you can see what it is
that I'm doing. But as you're examining,
patient's eyes, especially the pupils, or looking at the retina, you
would turn the light off. I'm going to bring over the opthalmoscope and I'm
going to show you a few aspects of this
ophthalmoscope so you can see what are the
characteristics here. First, this is the back
of the ophthalmoscope. This top part, you would
rest right on your forehead, and this is what you would look through this aperture here. And right down on the bottom
are a set of numbers, and that number you should
always have set at zero. This dial on the side
is how you would turn that number away from zero, but you're going to keep
it always on zero here. Now, turn the ophthalmoscope
around the other way. This is the patient side to show you some of
what you see here. There's one dial here that'll control the light
characteristics. Then there's another dial here that controls how
bright the light is. I'll show you how that works. I'll use Frank's gown here. First, the brightness,
this is this dial here. As you watch that light, you see that it's
getting brighter and dimmer as I'm
moving this around. When you're examining
someone's eye, when you're looking in
the back of their eye, you want to leave that light
source about in the middle, not super bright, not dim. Then the other
dial that I showed you for the source of the light. You can move that back
and forth to see first, a small amount of light,
medium amount of light, large amount of light,
and then you go to some other aspects that
we don't use in PDS, one is a target, a slit light, and
then a blue light. But what you want to use for the light source is
about the medium size. So medium size light source about medium intensity
of light here. Now, what I'm going
to check first is Frank's pupilary response. And as I said, I would typically dim the lights here, but
I'll keep them bright. So if you can look against
the opposite wall here. What I'm doing is I'm
shining the light in one eye here to see that the
pupil is constricting. While this pupil, the right
pupil is constricting, the other one should
also be constricting. Then I'll go over and
check the left pupil and see that the left pupil is constricting at the same time that the right pupil
is constricting. That's normal for both
pupils to constrict, even though light is
shining just in one pupil. Now the other part of this is the swinging flashlight test or checking to make sure that
pupils stay constricted. So I shine on this eye
and then I move over here for a couple of
seconds and back over here. I'm looking at both
pupils as I'm doing that to see that both
pupils are staying constricted as I move the light back and
forth as a way to check that the eyes
are both getting the same information
from the optic nerve. Now, the next part of this is also to check the optic disc. The main purpose of checking the optic disc is to be able to see the end of the optic nerve and to see the disc itself. The remainder of the
retina is made up of blood vessels and the
background of the retina. In PDS, it may be hard for you to identify
the optic disc. And so what I want you
to be able to do in your first year and into your second year is to be able to identify a blood vessel. And as you get more comfortable with evaluating blood vessels, then you want to
be able to focus in and find the optic disc. So I'll show you how I would
recommend that you do this. First, if I'm examining
Frank's right eye, first, I'm going to hold the
ophthalmoscope in my right hand, I'm going to use my right
eye and my left hand will be to stabilize myself with my hand on Frank's forehead so that I can tell how
far away I am from Frank's eye because
I need to get fairly close with
this ophthalmoscope, and I need to have some sign to myself of where I am in space. So what I'll do first is I'll put my
hand on your forehead, Frank here and I'm
going to hold this over my right eye then
looking at Frank's eye. What I'm seeing here
is a red reflex as I'm starting
about this far away. I'm a little bit
off center here, looking in Frank's eye and then I'm going to come
in closer here. And as I come in closer, I'm looking for a blood vessel. That's a red line across a
palish or orangish field. And as I find one of
those blood vessels, you see I focus in and I see it right about
at this distance. You can see about how far
away I am for Frank's eye, that'll vary a little
bit depending on your vision and the
patient's vision as to how close you need to get. Then once I find
the blood vessel, then I follow it and I follow
it to a yellowish disc, which is the optic disc. As I said, that's a
more advanced skill. If you find a blood
vessel right away, see if you can follow it to the center and see
an optic disc. Now, I'll move to the other eye. So what I'm going to do is I'm going to bring this
behind the patient. I'm going to now hold
this in my left hand. I'm going to look
at Frank's left eye and I'm using my left eye, and then I'll use my right hand to stabilize on his forehead. So I'll come in through
this direction. Again, identifying
the red reflex, and then coming in closer. I see blood vessels, and then I can move in
again to the optic disc. And that concludes
the eye exam today.