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22.02.2014
An eye examination is a battery of tests performed by an ophthalmologist or optometrist assessing vision and ability to focus on and discern objects, as well as other tests and examinations pertaining to the eyes.
External examination of eyes consists of inspection of the eyelids, surrounding tissues and palpebral fissure. An examination of pupilary function includes inspecting the pupils for equal size (1 mm or less of difference may be normal), regular shape, reactivity to light, and direct and consensual accommodation. If there is an efferent defect in the left eye, the left pupil will remain dilated regardless of where the light is shining, while the right pupil will respond normally. If there is a unilateral small pupil with normal reactivity to light, it is unlikely that a neuropathy is present.
Ocular motility should always be tested, especially when patients complain of double vision or physicians suspect neurologic disease.
Testing the visual fields consists of confrontation field testing in which each eye is tested separately to assess the extent of the peripheral field. To perform the test, the individual occludes one eye while fixated on the examiner’s eye with the non-occluded eye. Common problems of the visual field include scotoma (area of reduced vision), hemianopia (half of visual field lost), homonymous quadrantanopia (involving both eyes) and bitemporal hemianopia.
Intraocular pressure (IOP) can be measured by Tonometry devices designed to measure the outflow (and resistance to outflow) of the aqueous humour from the eye. Close inspection of the anterior eye structures and ocular adnexa are often done with a slit lamp machine. This allows inspection of all the ocular media, from cornea to vitreous, plus magnified view of eyelids, and other external ocular related structures. The binocular slit-lamp examination provides stereoscopic magnified view of the eye structures in striking detail, enabling exact anatomical diagnoses to be made for a variety of eye conditions.
Also ophthalmoscopy and gonioscopy examinations can also be performed through the slit lamp when combined with special lenses. Ophthalmoscopic examination may include visually magnified inspection of the internal eye structures and also assessment of the quality of the eye’s red reflex.
Ophthalmoscopy allows the one to look directly at the retina and other tissue at the back of the eye. This information is presented for education purposes, to make it easy for you to explore your vision correction options. For presbyopic examiners, a generous near correction is needed for adequate study of pupillary sizes, shapes, and movements.
If one or both pupils do not appear to react, a pathological state in need further examination has been found (go to the fourth step).
When a pupil is poorly reactive or does not react to a light stimulus, the swinging flashlight test cannot be done in the usual way since the test requires that both pupils react equally to light. The dilation test uses a comparison of the speed of pupillary dilation of both eyes after extinguishing a bright light stimulus. When the pupils dilate well and with no speed difference between them, the anisocoria is likely to be physiologic.
Observation of the pupils in the dark with infrared light is simpler and more effective than are examinations done under dimly illuminated conditions.
Drops of 5% cocaine are instilled in both eyes (all pharmacologic pupil testing should be done symmetrically, comparing one eye to the other). If 1 h after cocaine instillation there remains a difference between the pupillary sizes of 1 mm or more, this should be accepted as reasonable proof of Horner's syndrome (¦ Fig.
Thus, cocaine testing clearly differentiates physiologic an-isocoria from Horner's syndrome.
Dealing With DrugsGet All The Support And Guidance You Need To Be A Success At Dealing With Drugs. Marcus Gunn pupil or relative afferent pupillary defect (RAPD) is a medical sign observed during the swinging-flashlight test[1] whereupon the patient's pupils constrict less (therefore appearing to dilate) when a bright light is swung from the unaffected eye to the affected eye. The most common cause of Marcus Gunn pupil is a lesion of the optic nerve (between the retina and the optic chiasm) or severe retinal disease. In the swinging flashlight test, a light is alternately shone into the left and right eyes.
A Marcus Gunn Pupil is distinguished from a total CN II lesion, in which the affected eye perceives no light. Correll MH1, Datta N2, Arvidsson HS3, Melsom HA3, Thielberg AK4, Bjerager M4, Brodsky MC5, Saunte JP1.


BACKGROUND: Lyme neuroborreliosis (LNB) designates central nervous system involvement caused by the tick-borne spirochaete Borrelia burgdorferi (Bb). Post-illumination pupil response after blue light: Reliability of optimized melanopsin-based phototransduction assessment. Melanopsin-containing retinal ganglion cells have recently been shown highly relevant to the non-image forming effects of light, through their direct projections on brain circuits that regulate alertness, mood and circadian rhythms. The Neurologic Exam Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York. Andy Jagoda, MD Risk Management: Case #2 A 64-year-old male presented with lower back pain which had become progressively worse over the past 2 weeks. Health care professionals often recommend that all people should have periodic and thorough eye examinations as part of routine primary care, especially since many eye diseases are asymptomatic.
Palpation of the orbital rim may also be desirable, depending on the presenting signs and symptoms. The swinging-flashlight test is the most useful clinical test available to a general physician for the assessment of optic nerve anomalies. If there is an afferent defect in the left eye, both pupils will dilate when the light is shining on the left eye, but both will constrict when it is shining on the right eye.
First, the doctor should visually assess the eyes for deviations that could result from strabismus, extraocular muscle dysfunction, or palsy of the cranial nerves innervating the extraocular muscles. The patient is then asked to count the number of fingers that are briefly flashed in each of the four quadrants. A small beam of light that can be varied in width, height, incident angle, orientation and colour, is passed over the eye. Fluorescein staining before slit lamp examination may reveal corneal abrasions or herpes simplex infection. If a parent suspects something is wrong an ophthalmologist or optometrist can check even earlier. HOWEVER, no matter how reliable information on this or any website may be, there is no substitute for a professional examination of your eyes and a face-to-face discussion of your unique situation.
This anatomically bilateral sharing of neural input has the important consequence that damage to the afferent visual pathways that lead to the Edinger-Westphal nucleus cannot cause an anisocoria.
Pupillary examinations are usually best done in a dimly illuminated, nearly dark room (see below), which makes proper correction of the examiner's refractive errors particularly important. Only in the dark can the pupils really show how well they can react, so be sure that the room light is as dim as convenience will allow.
Examination and interocular comparison of the pupillary diameters determines whether the autonomic (efferent) innervation of the eye is intact. Illuminate both eyes from a position below the visual axis and then slowly bring the light source closer to the eyes. Moreover, if there is an anisocoria, the requirements for this test are somewhat different.
It determines whether there is evidence of a problem with sympathetic innervation of the pupil(s).
Physiologic anisocoria of greater than 1 mm is very uncommon, so when the difference is greater than 1 mm, use of the cocaine test is necessary (see below). A Marcus Gunn pupil indicates an afferent defect, usually at the level of the retina or optic nerve. The affected eye still senses the light and produces pupillary sphincter constriction to some degree, albeit reduced. A normal response would be equal constriction of both pupils, regardless of which eye the light is directed at.
The pain was primarily in the lower back without radiation, with nonspecific numbness in the legs. The conjunctiva and sclera can be inspected by having the individual look up, and shining a light while retracting the upper or lower eyelid. This is because the left eye will not respond to external stimulus (afferent pathway) but can still receive neural signals from the brain (efferent pathway) to constrict. Saccades are assessed by having the patient move his or her eye quickly to a target at the far right, left, top and bottom. This method is preferred to the wiggly finger test that was historically used because it represents a rapid and efficient way of answering the same question: is the peripheral visual field affected? A limited view can be obtained through an undilated pupil, in which case best results are obtained with the room darkened and the patient looking towards the far corner.The appearance of the optic disc and retinal vasculature are the main focus of examination during ophthalmoscopy.


If you are experiencing any difficulty with your vision, you should schedule an eye examination. Thus, anisocoria is never a sign of an afferent disturbance, but is always a sign of an efferent pupillary disorder. The patient should be asked to look into the distance, to limit intrusion by the miosis of the near reflex. If there is an anisocoria, repeat testing of both pupils' responses to a strong, binocular light stimulus. Experience has found that when there is an interocular difference of 0.5 mm or more in pupillary diameter, the test is best done by judging the movements of the pupil that has the better light reaction, comparing its direct and consensual responses. Typical responses of the pupils in the normal state and in the classical pupillary disorders during routine examination. A practical alternative is to use a separate, weak light source to illuminate both eyes at a tangential angle from below, so that both pupils are visible and a minimum area of retina is being illuminated in each eye.
When sympathetic innervation is intact, there is a constant rate of release of noradrenalin into the synapse, and cocaine blocks its reuptake, causing an accumulation of the neurotransmitter, and resulting in pupillary dilation. If there is any uncertainty about the completeness of an application to either eye, the drop should be immediately repeated. Moving a bright light from the unaffected eye to the affected eye would cause both eyes to dilate, because the ability to perceive the bright light is diminished. Patient was treated with Compazine, 10 mg IV, with “resolution of headache” and discharged home to “follow-up With PMD”.
The examiner views the illuminated ocular structures, through an optical system that magnifies the image of the eye. This is the physiologic foundation for the tests to be described in the following sections of this chapter.
Using a strong light source (such as an indirect ophthalmoscope) stimulate both eyes simultaneously. It is best not to look at the eye with the brighter stimulus, since this causes light adaptation of the examiner's eyes, making it difficult to see the dimly illuminated pupil. If the anisocoria is physiologic, the smaller pupil dilates more than does the larger pupil, reducing the aniso-coria.
In the United States, where random testing by employers is common, subjects tested with cocaine should be given certificates indicating that they have been exposed to cocaine as a medical testing agent. When the test is performed in an eye with an afferent pupillary defect, light directed in the affected eye will cause only mild constriction of both pupils (due to decreased response to light from the afferent defect), while light in the unaffected eye will cause a normal constriction of both pupils (due to an intact efferent path, and an intact consensual pupillary reflex). In a normal reaction to the swinging-flashlight test, both pupils constrict when one is exposed to light. These eight fields of gaze test the extraocular muscles: inferior, superior, lateral and medial rectus muscles, as well as the superior and inferior oblique muscles. This part of the examination is done from a distance of about 50 cm and is usually symmetrical between the two eyes. Such devices are reasonably inexpensive, making their use for pupillary testing very attractive. The diameters of both pupils are measured before and 1 h after instillation of the drops, using the same levels of illumination for both measures. Only 3% of Horner's-affected pupils respond with a dilation of more than 1 mm, so when cocaine produces a dilation of 1.5 mm or more, Horner's syndrome can be effectively ruled out. The effect of topical administration of a 5% solution of cocaine to the eye can be detected in urine samples for several days.
Thus, light shone in the affected eye will produce less pupillary constriction than light shone in the unaffected eye. As the light is being moved from one eye to another, both eyes begin to dilate, but constrict again when light has reached the other eye. It is usually sufficient to measure the pupils' diameters with a pocket card that has semicircles of various diameters arrayed along one margin.



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