Ординатура / Офтальмология / Английские материалы / Practical Ophthalmology A Manual for the Beginning Ophthalmology Residents 4th edition_Wilson_1996

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because the exact location of the superior and inferior limbus is harder to define. The corneal diameter is measured in patients suspected to have a developmental disorder of the globe.

Better ways than gross inspection are available to evaluate corneal topography, but a quick look from the patient's side, aligning your view along the iris plane, helps to discern severe ectasia, as in keratoconus. Another way to detect a corneal deformity is to look at the contour of the lower eyelid border as the patient looks down. For example, Munson's sign is the angular curvature of the lower lid produced by keratoconus. The retinoscope and direct ophthalmoscope can also be used to detect refractive changes caused by abnormal corneal topography.

The depth of the anterior chamber can be checked during the external examination. Diffuse and narrow-beam penlight techniques for doing so are described in Clinical Protocol 9.7. In the penlight technique, the angle of the anterior chamber is classified bv the relative positions of the anterior iris and the posterior cornea (Table 9.7). Gonioscopv is performed whenever an anterior chamber angle abnormality is suspected (see Chapter 11). .

Suspected lesions inside the eye can be assessed by using a transilluminator or bright penlight. Clinical Protocol 9.8 describes specific techniques of transscleral illumination and transpupillary retroillumination.

Palpation

Feeling for abnormalities involves tactile, proprioceptive, and temperature senses. The considerate examiner avoids sudden, unexpected touches on or around the eyes, particularly in patients with poor vision

Table 9.7 Method of Grading the Anterior Chamber Angle

Palpation 187

and in sighted people who have their eyes closed. Explaining the examination's goals helps to reassure patients during palpation.

A screening examination is done routinely as follows:

1.Use the middle fingers to check for preauricular lymph nodes.

2.Use the index fingers and thumbs to open the eyelids wide apart.

3.Ask the patient to gaze in different directions to expose most of the ocular surface as you inspect the globe.

4.Judge and record any mass according to its size, shape, composition, tenderness, and movability.

A more detailed examination is done when necessary, such as in suspected trauma or with a congenital anomaly. Cranial nerve function may also need to be assessed (see Clinical Protocol 9.1). The examiner performs a coordinated palpation sequence in the following order:

•Head and face

•Bones

•Blood vessels

•Lymph nodes

•Orbit

•Eyelids

•Globe

Note frontal bossing and other anomalous bony changes. Tenderness over the maxillary or frontal sinus may be a sign of paranasal sinusitis.

Palpation of the temporal artery in elderly patients might reveal tenderness with hardening and tortuosity during acute episodes of giant-cell arteritis. Palpation ot the neck vessels is done to check for a carotid arterial pulse and for a jugular venous hum (Figure 9.6).

Certain types of infections produce enlarged lymph nodes. Palpation for an enlarged preauricular (superficial parotid) lymph node is done by placing the fingers below the patient's temple, just in front of the tragus. This node is normally neither tender nor palpable. Palpate the submandibular lymph nodes located under the angle of the jaw. Superficial cervical lymph glands—the jugular, poststernocleidomastoid, and supraclavicular nodes—are palpated in patients with suspected lymphadenopathy. The locations of these lymph nodes are shown in Figure 9.7.

188 Chapter 9: External Examination

Figure 9.6 Palpation of the carotid puise. (A) Placement of the examiner's thumb from the front. (B) Placement of the examiner's fingers from behind.

A .

Figure 9.7 Lymph nodes inspected or palpated during the external ophthalmic examination. Shaded areas show the lymphatic drainage of the ocular adnexa to the preauricular and submandibular nodes.

Orbit

Clinical Protocol 9.9 describes the methods of palpating the orbital margins and contents of patients with head trauma who mav have fractures. A step-off may indicate a facial fracture. Simultaneous palpation of both sides makes it easier to identify abnormalities. In all cases of suspected orbital trauma, the examiner must first be certain of the

Palpation 189

integrity of the globe before any manipulations are done. If a ruptured globe is suspected, do not palpate directly. Instead, hold the eyelids of an injured eye open by directing the upper lid onto the brow and the lower lid onto the cheek without pressing on the globe. Note major discrepancies from the normal anatomy in the medical record.

Eyelids

Gentle palpation of the closed lids is done by sliding the examining finger over the eyelid skin. This maneuver can be helped by stretching the skin and having the patient rotate the globe so the examiner does not press on the cornea. A mass can sometimes be felt even when it is difficult to see. The examiner should note the presence of an eyelid mass and whether the eyelid margin or conjunctiva is involved. The dimensions of an eyelid lesion should be measured with a millimeter ruler. Generally, the longest diameter and its perpendicular are recorded, along with the lesion's consistency and movability.

To test for the presence of a Bell's phenomenon (activated superior rectus function during inhibited levator function), ask the patient to shut the eyelids and to keep them closed while you gently pry the eyelids open and peek at the position of the globes. Determining what part of the globe lies behind the interpalpebral fissure is important if there is incomplete eyelid closure.

Lacrimal System

Any mass of the lacrimal gland or lacrimal sac is evaluated for size and tenderness. A patient with epiphora should undergo compression of the sac to learn if material can be refluxed from the puncta. Clinical Protocol 9.10 describes lacrimal sac compression and the dye disappearance test, which are the principal diagnostic tests for a patient with excess tears.

Globe

Applying fingertip pressure onto the eyeball through the eyelid can help determine whether congested vessels can be blanched (suggesting conjunctival vascular dilation) or not (such as with ciliary flush or episcleritis) and whether a nodule is movable (suggesting a conjunctival phlyctenule or episcleral nodule) or not (such as with nodular scleritis). The location of any focal tenderness should be noted.

Schirmer testing, used for patients with dry eye, is described in Clinical Protocol 9.11. The examiner uses sterile filter paper strips (30

Auscultation

Auscultation for an orbital bruit is performed by placing the bell of the stethoscope over die closed eyelids as the patient briefly holds his or her breath. A small pediatric bell works well. The noise of eyeball movement can be eliminated by instructing the patient to open the eyelids of the opposite eye and fixate on a straight-ahead target. The stethoscope bell can also be placed over the frontal sinus and on the temple to listen around the orbit.

Faint rumbling sounds heard over the globe can be normal. An orbital bruit can signify the presence of a carotid-cavernous fistula or an arteriovenous malformation. The bruit is usually accentuated during systole and decreases with compression of the ipsilateral carotid artery or both jugular veins.

The neck can be examined for a carotid bruit by listening over the carotid bifurcation just below the jaw angle. Chest auscultation is necessary to ensure that a cardiac murmur is not being transmitted to the neck. Some ophthalmologists include blood pressure measurement in their initial eye examination.

Pitfalls and Pointers

•Be professional and nonjudgmental during the external examination. The patient is also examining the examiner and is sensitive to offhand remarks and nonverbal signs that could be misinterpreted. Conversing with the patient helps to distract the patient from your observation and palpation tasks.

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Wash your hands between all patients. Washing your hands in the room just before starting the external examination shows the patient you follow recommended precautions and often alleviates some anxiety. Warm, dry, clean, and manicured hands are appreciated by everyone.

Don't rush to examine the obvious lesion and ignore the rest of the external examination. Sit back, get an overview, and proceed carefully and thoroughly through the stepwise procedure.

Don't forget to compare the abnormal eye with the fellow one. Back-and-forth comparisons between the two sides of the face can reveal a subtle asymmetry.

Compare your findings with previous records. Looking at old photographs, including driver's licenses, can reveal an unrecognized but long-standing ptosis or asymmetry. If necessary, have the patient bring in old photographs from home. The examiner should also have photographs taken whenever possible to document trauma, presurgical appearance, and any lesion that may be growing.

Be careful when measuring the lid fissure height. The position of the eyelids will change depending upon eye position, facial muscle activity, alertness, and external stimuli such as phenylephrine eyedrops. Check the palpebral fissure in primary position with eyes gazing at a distance target. Don't forget to observe the brow for ptosis, compensatory elevation, and wrinkling.

Be gentle. Pressure on the globe may elicit the oculocardiac reflex and produce bradycardia in susceptible individuals. Be sure to warn the patient about what to expect during procedures such as lid eversion.

Orbit, Eyelids, and Lacrimal System. Basic and Clinical Science Course, Section 7. San Francisco: American Academy of Ophthalmology; updated annually.