Visual Acuity is the Key Vital Sign

“The Blood Pressure of the Eye”

We need an efficient routine….
Have the non-physician clinical staff do it
When First, (except chemical injury – irrigate)
Where Anywhere it can be done
How: one eye at a time
glasses on
encourage but beware of the peeker
distance: (20 feet or 6 meters)
near: comfortable reading
standard chart (or the printed page)
how to measure (majority rules)
how to document it  “20/20+2”
The Pupil Exam: Relative Afferent Pupil Test
For the patient who can’t or won’t give us an acuity or
“gives us an acuity that we want to give back”
How to do it

How to use it
Poor or no acuity and normal pupil reaction
Maybe hysteria or malingering
Normal/good acuity and abnormal pupil reaction
Early optic nerve disease
A Dilated and fixed pupil is not an afferent pupil
 Exam: Looking at the Eye
The external exam
Brow, lids, soft tissue at orbital rim
The front of the eye
The conjunctiva to the lens
No magnification “A boy named S.U.E.” (Screwed Up Eye)
Woods Lamp or any blue light plus Fluorescien dye R.O.Y. G. B.I.V.
Produces that green glow that we know as fluorescence
How: 1. anesthetic drop in eye
2. wet Fluorescein strip with anes. Drop
3. quickly and gently touch wet strip to inside lower lid
4. have patient blink slowly 2-3 times (total time of 3-5 seconds)
5. look with blue light for fluorescence

Slit lamp (magnification and bright colored light)

Intraocular pressure: Tonopen or Goldman, (no SchiØtz please)

 Exam: Looking at the Eye
The back of the eye Usually not needed (blasphemy for a retina surgeon)
Direct ophthalmoscopy (without dilation) Good luck! – “a long run for a short slide”

+ ≠

Important exceptions:
Pediatric Red Reflex Optic Nerve Evaluation
Posterior Vitreous Detachment
“cobwebs”, “bugs”
Vision is usually normal
Age related event:
liquefied vitreous moves
away from the posterior
retina
10% less than 50y
65% over 70y
Increases with myopia
and history of intraocular surgery

15% have retina tear that could lead to RD

70% have tear, if vitreous hemorrhage present
Retinal Detachment
Rhegmatogenous Retinal Detachment (RRD)
Most common
Causes: PVD with break or trauma causing break, or “weak”
retina (high myopia) allowing liquefied vitreous behind retina
Quickly lose vision usually preceded by floaters, flashers,
and visual field loss
Tractional Retinal Detachment (TRD)
secondary to significant, persistent vitreo-retinal traction:
DM, trauma, any cause of vitreous hemorrhage
slowly loss vision, may see floaters typically does not see
flashers, or visual field loss
Exudative Retinal Detachment (ERD)
rarest, causes include ocular tumors (primary or metastatic)
and ocular inflammation – treat the underlying cause
Retinal Detachment
Triage:

Refer to an Ophthalmologist (THE EYE MD)

If the symptoms started that day, the patient should be seen

within 24 hours
If the symptoms are several days old, they should be seen in
within 1-2 days
If symptoms are over a week, then patient should be seen
within a week

The ophthalmologist will examine the eyes several times over

3-4 month period, each exam will require pupil dilation
Treatment: Retinal Breaks and Detachment
Search for the breaks
Seal the breaks
Laser or cryopexy

Support the breaks

Pneumatic retinopexy
Scleral buckle

Sever the vitreous traction

Vitrectomy
References
The Massachusetts Eye and Ear Infirmary,
Illustrated Manual of Ophthalmology
Saunders, Concise outlines (Hx->Tx), color photos
good for clinic/ED
The Wills Eye Manual
Lippincott Williams and Wilkins, Concise outlines
well known to ophthalmologists, no photos, good for
clinic/ED
Ophthalmology for the Primary Care Physician
Mosby, Concise paragraph form, color photos, could
read as text and should be fine in clinic/ED
Things to Remember
1. What is the “blood pressure” of the eye?
2. What is a posterior vitreous detachment (PVD)?
3. Why do we worry about a PVD?
4. What are the types of retinal detachments (RD)?
5. What is the most common type of RD?
6. What should you do for a patient with PVD?
7. What are the basic steps to treat a retinal detachment?

Questions?