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Rangsima Poomsawat
            Department of Public Health Nursing
           Faculty of Nursing Chiang Mai University
               E mail: rangsima@ chiangmai.ac.th
                                                 http://www.facebook.com/RangsimaPoomsawat
                                                               http://www.slideshare.net/rpoom
                                                  http://www.youtube.com/RangsimaPoomsawat
           http://www.facebook.com/pages/Nursing-Room-By-Rangsima/109937325743807?v=wall
Oct/2008                    rangsima@chiangmai.ac.th                                1
Contents
 1.    History Taking
 2.    Ocular Symptomatology
 3.    Visual Acuity Test
 4.    External Eye Examination
       1. Eye Lids
       2. Eyeball
       3. Lacrimal System
       4. Conjunctiva
 5. Anterior Segment Examination
       1. Cornea
       2. Anterior Chamber
       3. Iris
       4. Pupil
       5. Lens
 6. Testing of Function of Extraocular Muscles
Oct/2008               rangsima@chiangmai.ac.th   2
Oct/2008   rangsima@chiangmai.ac.th   3
• The purpose of the
                   interviewing a client is to
                   obtain a health history.
                 • Ask about the symptoms or
                   other phenomena associated
                   with the client’s chief
                   problems or concerned and at
                   the same time observes for
                   signs in the client’s physical
                   appearance or behaviors.

Oct/2008   rangsima@chiangmai.ac.th           4
• Introductory phase
   – To create a climate of trust to promote interaction
   – Introduce yourself : your full name, your role
     **This greeting respectfully acknowledges the
     clients and conveys your accountability as part of
     health care team
   – Describe your purpose of the interview



Oct/2008           rangsima@chiangmai.ac.th          5
• Working phase
    – You and the client should both be comfortably seated and
      facing each other during the interview.
    – To put the client ease, directly state that the information
      you obtain will be confidential, recorded in the medical
      record,and share with those directly involved in the care
      and treatment plan.
    – Take some note and complete final record later.
    – Eye Practitioner may be skillful in communication
      techniques to enable a client to share life experiences
      relevant to his health status.

Oct/2008               rangsima@chiangmai.ac.th               6
Interview Techniques
 Type of Questions
  – Opened ended : broad opening statements
       • Your concern today is….?
       • Tell me what bring you here today?
  – Closed ended : requires a response of one or two
    words,such as yes or no
       • Age, Marital status, Medication
  – Directive questions : lead the client to focus on one set of
    thought
       • Used in review of system or in evaluating functional health status.
       • Have you experienced any problem with urination in the past,such
         as infection ,unusual frequency, urgency, or difficulty urination?
  – Permission-giving questions
       • Asks client questions about sensitive area : Sexual transmitted
         infection
       • Let a client know that it is all right to speak such things to you.
Oct/2008                    rangsima@chiangmai.ac.th                           7
Interview Techniques
 Use of Silence
     Short period of silence allow the clients organize their
     thoughts.
     During silence period,you can observe the clients
     emotional state and note nonverbal cues.
     Silence may also indicate that either you or the client need
     time to reflect on what was just said.




Oct/2008               rangsima@chiangmai.ac.th                8
Validating Information From the Interview
• Clarification : ask the client to clarify the thought or
  feeling
• Restatement : involves repeating what the client has
  said using different word.
• Reflection : repeat phrase or sentence the client just
  said.
• Confrontation : make the client aware that what you
  observe is not consistent with he said.
• Interpretation : share with the client the conclusion
  you have drawn from the information you obtained
• Summary : summarize the information when
  terminate interview
Oct/2008            rangsima@chiangmai.ac.th            9
Nonverbal Communication
• Body language :
   – Body Posture, Facial expressions are indicators of emotional
     states such as fear anxiety, surprise or joy
• Eye contact
   – Avoid eye contact during interviewing may have anxiety
• Interpersonal Distance : vary by the nature or cultural
  practice
• Touch : express appreciation and trust by touch



 Oct/2008              rangsima@chiangmai.ac.th             10
Organization of A History

  •   Introductory Data
  •   Chief complaint
  •   Present illness
  •   Past History
  •   Personal History
  •   Family History
  •   Review of System



Oct/2008              rangsima@chiangmai.ac.th   11
Introductory Data
•Included under general information are the essential facts

             – Name, Address, Date of birth , Age,
               Sex
             – Occupation
                • Type of work
                • Industrial hazard



  Oct/2008           rangsima@chiangmai.ac.th         12
Chief Complaint : CC
  The main reason for which the patient has come to
            the doctor for advice and help
    Include a notation of the duration of problem
• Blurred Vision ****
• Ocular pain (ocular ache) , Burn sensation ***
• Discharge
• Red eye
• Itching
• Changes in vision or visual fields
• Difficulty reading
• Oct/2008 cyst , stye , exophthalmos
  Etc :                    rangsima@chiangmai.ac.th   13
Example of good statements of CC

• “Blurred vision Right eye for 7 days”
• “Headache and fever for 6 hours.”
• “Vision test needed for work”




Oct/2008        rangsima@chiangmai.ac.th   14
Greater detail of
main symptoms                        Present Illness :PI
•      Duration :
      – How long has this condition lasted? Is it similar to a
         past problem? If so, what was done at that time?

•      Onset : sudden or gradually

•        Severity/ Character
        – How bothersome is this problem? Does it interfere
             with your daily activities?
        – If they are describing pain, ask them to rate it from 1 to
             10 with 10 being the worse pain of their life
        – When describing pain, ask if it's like anything else that
             they've felt in the past. Knife-like? A sensation of
             pressure? A toothache?
        – If it affects their activity level, determine to what
    Oct/2008
             degree this occurs.
                              rangsima@chiangmai.ac.th             15
Present Illness : PI
•     Location/ Radiation : unilateral or bilateral
     – Is the symptom (e.g. pain) located in a specific place?
        Has this changed over time? If the symptom is not
        focal, does it radiate to a specific area of the body?

•      Pace of illness: Is the problem getting better, worse, or
       staying the same? If it is changing, what has been the
       rate of change?

•      Are there any associated symptoms? If so, what's made it
       better (or worse)?

•      Have they tried any therapeutic maneuvers? If so, what's
       made it better (or worse)?

•      What do they think the problem is and/or what are they
       worried it might be?
    Oct/2008               rangsima@chiangmai.ac.th                16
Present Illness : PI
•     Why today?
     – This is particularly relevant when a
        patient chooses to make mention of
        symptoms/complaints that appear to be
        long standing.
     – Is there something new/different today
        as opposed to every other day when this
        problem has been present?
     – Does this relate to a gradual worsening
        of the symptom itself?




Oct/2008             rangsima@chiangmai.ac.th     17
Past History : PH
• Past Ocular Problem /Trauma / Ocular surgery :
  repeat , chronic
           • Herpetic stromal keratitis
           • Aphakia , Lens Extraction
• Visual acuity in the past / Eye glasses
           • Myopia , Presbyopia , Astigmatism
• Past Medical History
           • Hypertension, Diabetic Mellitus, Thyrotoxicosis
           • Malaria, Tuberculosis **
• Past Surgical History
• Accident and disabling injuries
• Hospitalization (including Blood transfusion)

Oct/2008                    rangsima@chiangmai.ac.th           18
Past History : PH

• Medications (ocular or other)
           •   Mydriatics Myotics
           •   Steroid
           •   Ethambutol , Quinine, Chloroquine
           •   Epinephrine , silver nitrate
           •   Herbal preparation or nutrition supplement




Oct/2008                   rangsima@chiangmai.ac.th         19
Past History : PH
   • Allergies/Reactions
      – Environment :Inhalants Contactants
      – Food : Ingestants
      – Medication
   • Pediatric:
      – Growth and Development
      – Immunization




Oct/2008          rangsima@chiangmai.ac.th   20
Personal History

• Habits :Smoking / Alcohol /Caffeine/Drugs
• Sexual Activity




Oct/2008       rangsima@chiangmai.ac.th   21
Family History : FH

    • Heritable illnesses
           • Color blindness , Retinoblstoma
           • Myopia ,Glaucoma
    • Chronic Disease
           • DM Hypertension

    • Communicable diseases(including
      family Sibling Sex partner)
           • HIV
           • TB
           • Malaria
Oct/2008               rangsima@chiangmai.ac.th   22
Review of Systems

• Health History :
     –     Head and Neck
     –     Thorax and Lung
     –     Heart
     –     Abdomen
     –     Musculoskeletal
     –     Neurological
     –     Mental

Oct/2008              rangsima@chiangmai.ac.th   23
Contents
    History Taking
    Ocular Symptomatology
    Visual Acuity Test
    External Eye Examination
       Eye Lids
       Eyeball
       Lacrimal System
       Conjunctiva
    Anterior Segment Examination
       Cornea
       Anterior Chamber
       Iris
       Pupil
       Lens
    Testing of Function of Extraocular Muscles
Oct/2008             rangsima@chiangmai.ac.th     24
Oct/2008   rangsima@chiangmai.ac.th   25
Ocular Symtomatology


           • Visual Symptoms
           • Non-Visual Symptoms




Oct/2008          rangsima@chiangmai.ac.th   26
Oct/2008   rangsima@chiangmai.ac.th   27
Blurred vision

             •   Monocular, Binocular
             •   Sudden , Progressive
             •   Distance : Near Far
             •   Character
             •   Duration




Oct/2008   rangsima@chiangmai.ac.th     28
Blindness
           • VA < 6/60
           • VF < 20 degree


                       • Cause
                            – Cataract
                            – Glaucoma
                       • Type
                            – Cortical Blindness
                            – Perceptual


Oct/2008         rangsima@chiangmai.ac.th           29
Amsler’s Grid                              Metamorphopsia




Oct/2008         rangsima@chiangmai.ac.th            30
Visual Symptoms
      •Micropsia                              •Macropsia




Oct/2008           rangsima@chiangmai.ac.th                31
Iridescent Vision




Oct/2008   rangsima@chiangmai.ac.th      32
Chromatopsia




Oct/2008   rangsima@chiangmai.ac.th        33
Floater




Oct/2008   rangsima@chiangmai.ac.th   34
Diplopia




Oct/2008   rangsima@chiangmai.ac.th   35
Photopsia

            Photophobia


                            Visual Field Defect




Oct/2008    rangsima@chiangmai.ac.th       36
Night Blindness


           Day Blindness


                             Color Blindness



Oct/2008    rangsima@chiangmai.ac.th     37
Oct/2008   rangsima@chiangmai.ac.th   38
Headache


      Ocular Ache




Oct/2008      rangsima@chiangmai.ac.th   39
Burning Sensation




           Foreign Body Sensation



Oct/2008          rangsima@chiangmai.ac.th   40
Itching


           Pulling Sensation




Oct/2008     rangsima@chiangmai.ac.th   41
Red Eye


Discharge




 Oct/2008   rangsima@chiangmai.ac.th         42
Dry Eyes




    Lid Swelling
Oct/2008     rangsima@chiangmai.ac.th          43
Exophthalmos




Discoloration



 Oct/2008       rangsima@chiangmai.ac.th   44
Contents
 History Taking
 Ocular Symptomatology
 Visual Acuity Test
 External Eye Examination
    Eye Lids
    Eyeball
    Lacrimal System
    Conjunctiva
 Anterior Segment Examination
    Cornea
    Anterior Chamber
    Iris
    Pupil
    Lens
 Testing of Function of Extraocular Muscles
Oct/2008           rangsima@chiangmai.ac.th    45
• Assessment of the eye's
                          ability to distinguish
                          object details and shape,
                          using the smallest
                          identifiable object that can
                          be seen at a specified
                          distance (usually 20 ft. or
                          16 in.).

Oct/2008   rangsima@chiangmai.ac.th              46
• Finding normal VA
    >>
     – Clarity of cornea anterior body Lena Vitreous
       Humor
     – adequacy of macular (central vision)
     – Functioning of nerve fiber from macula to the
       occipital cortex


Oct/2008            rangsima@chiangmai.ac.th           47
For distant vision




 Oct/2008     rangsima@chiangmai.ac.th   48
For Near vision:
• Near vision is tested by using a
  test card and each eye is tested
  individually.
• The card has number of printed
  paragraphs with print of varying
  sizes. Each paragraph is described
  in terms of “points” measuring
  the body of the print – where a
  “point” is 1/72 of an inch.
• In a common test, N48 is the
  largest type, and N5 is the
  smallest, which an unimpaired
  eye can see, held at a comfortable
  reading distance, (usually 14
  inches), from the eyes.
Oct/2008             rangsima@chiangmai.ac.th   49
Equipment
Oct/2008     rangsima@chiangmai.ac.th   50
Oct/2008   rangsima@chiangmai.ac.th   51
วัดสายตา




Oct/2008          rangsima@chiangmai.ac.th   52
Oct/2008   rangsima@chiangmai.ac.th   53
Oct/2008   rangsima@chiangmai.ac.th   54
Snellen chart
•    Distance 6 m. or 20 ft.
•    Without glasses                                SC               6/24 , 6/36
•    with glasses                                   CC               6/9 , 6/9
•    With pinholes                                  CC PH            6/6 , 6/6
•    Interprete VA (visual acuity)
    numerator denotes the distance the patient is from the chart letter

    denominator denotes the distance from the chart at which normal person
    Oct/2008                    rangsima@chiangmai.ac.th                     55
Visual acuity
•   6/6, 6/9, 6/12, 6/18, 6/24, 6/36, 6/60
•   5/60, 4/60, 3/60, 2/60, 1/60
•   FC 2 ft, FC 1 ft (finger count)
•   HM (hand motion)
•   PJ (projection of light)
•   PL (perception of light)
•   NLP (no light perception)


Oct/2008           rangsima@chiangmai.ac.th         56
VA with pinholes

  • Improve : R/O refractive error
  • No improve or worse : R/O Ocular
    disease

SC         6/24 , 6/36           SC         6/12 , 6/9
SC c PH    6/9 , 6/9             SC c PH    6/24 , 6/12
Oct/2008         rangsima@chiangmai.ac.th            57
VA Test in Children




Oct/2008   rangsima@chiangmai.ac.th   58
Oct/2008   rangsima@chiangmai.ac.th   59
Contents
      History Taking
      Ocular Symptomatology
      Visual Acuity Test
      External Eye Examination
         Eye Lids
         Eyeball
         Lacrimal System
         Conjunctiva
      Anterior Segment Examination
         Cornea
         Anterior Chamber
         Iris
         Pupil
         Lens
      Testing of Function of Extraocular Muscles
  Oct/2008             rangsima@chiangmai.ac.th     60
• Torch light, Pen light
• Magnifier
                                                Equipment
• Eye pad
• Cotton bud
• Fluorescine strip
• Direct
  Ophthalmoscope
• Topical anesthesia




    Oct/2008         rangsima@chiangmai.ac.th           61
Oct/2008   rangsima@chiangmai.ac.th   62
External Eye


 •   Orbit
 •   Eyelid
 •   Eyelash
 •   Lacrimal system
 •   Conjunctiva



Oct/2008         rangsima@chiangmai.ac.th       63
Anatomy




Oct/2008   rangsima@chiangmai.ac.th   64
Herpes Zoster Ophthalmicus
                                                  Ecchymosis




    Cellulitis - Preseptal                  Cellulitis - Orbital




   Oct/2008            rangsima@chiangmai.ac.th                    65
Exophthalmos             Enophthalmos




 Buphthalmos
                                          Lagophthalmos




  Oct/2008     rangsima@chiangmai.ac.th             66
Trichiasis                              Distichiasis




                                           Poliosis
                    Vogt Koyanagi Harada syndrome-
Oct/2008     rangsima@chiangmai.ac.th             67
Entropion                                   Ectropion




                  Molluscum
                 Contagiosum

   Xanthelasma                                Carcinoma




    Oct/2008     rangsima@chiangmai.ac.th                 68
Dermatochalasis                                 Blepharochalasis




Levator dehiscence                                    Ptosis




 Oct/2008            rangsima@chiangmai.ac.th             69
Hordeolum                                Chalazion




    Blepharitis




Oct/2008          rangsima@chiangmai.ac.th               70
Coloboma                              Epicanthus




Oct/2008   rangsima@chiangmai.ac.th                71
Lacrimal System Anatomy




Oct/2008         rangsima@chiangmai.ac.th   72
Oct/2008   rangsima@chiangmai.ac.th   73
Dry Eye Syndrome                                      Tear




• Alacrima                           • Lacrimal Hypersecretion
   – Hereditary or congenital
     deficiency or absence of
     tear secretion.


  Oct/2008              rangsima@chiangmai.ac.th          74
Oct/2008   rangsima@chiangmai.ac.th   75
Dacryocystitis




Oct/2008              rangsima@chiangmai.ac.th   76
Conjunctival Anatomy




Oct/2008       rangsima@chiangmai.ac.th   77
Oct/2008   rangsima@chiangmai.ac.th   78
Oct/2008   rangsima@chiangmai.ac.th   79
Oct/2008   rangsima@chiangmai.ac.th   80
The Red Eye
    Conjuncival injection




               Red eye


Circumcorneal or ciliary injection

    Oct/2008          rangsima@chiangmai.ac.th        81
Subconjunctival Hemorrhage




                                                 Discharge




   Oct/2008           rangsima@chiangmai.ac.th               82
Oct/2008   rangsima@chiangmai.ac.th   83
Papilla & Follicle
                         Papillary hypertrophy




                                   Cobble stone papillae




 Oct/2008      rangsima@chiangmai.ac.th               84
Chemosis                              Symblepharon




Inflamed Pingueculum                          Pterygium




Oct/2008         rangsima@chiangmai.ac.th                 85
Betot spot
                                       Phlyctenules




Oct/2008        rangsima@chiangmai.ac.th         86
Oct/2008   rangsima@chiangmai.ac.th   87
Oct/2008   rangsima@chiangmai.ac.th   88
Oct/2008   rangsima@chiangmai.ac.th   89
Foreign Body




Oct/2008   rangsima@chiangmai.ac.th   90
Contents
                        History Taking
                        Ocular Symptomatology
                        Visual Acuity Test
                        External Eye Examination
                           Eye Lids
                           Eyeball
                           Lacrimal System
                           Conjunctiva
                        Anterior Segment Examination
                           Cornea
                           Anterior Chamber
                           Iris
                           Pupil
                           Lens
                        Testing of Function of Extraocular
                         Muscles

Oct/2008       rangsima@chiangmai.ac.th                   91
Oct/2008   rangsima@chiangmai.ac.th   92
Anterior Segment Anatomy




Oct/2008          rangsima@chiangmai.ac.th   93
Corneal Anatomy




Oct/2008   rangsima@chiangmai.ac.th   94
Corneal light reflex




Oct/2008       rangsima@chiangmai.ac.th   95
Megalocornea                                            Arcus senilis




        Herbert’s pit                              Corneal Edema




 Oct/2008               rangsima@chiangmai.ac.th                96
Cornea Haze                              Corneal Abrasion




 Oct/2008     rangsima@chiangmai.ac.th              97
Dermoid cyst                  Rheumatoid Scleromalacia
                              Perforans



            Corneal Ulcer


                                   Rheumatoid
 Oct/2008                          Corneal Ulceration
                    rangsima@chiangmai.ac.th            98
Pannus




           Foreign Body
Oct/2008            rangsima@chiangmai.ac.th   99
Blinking reflex
                               Slight Discomfort
                                  Lacrimation
Oct/2008   rangsima@chiangmai.ac.th          100
Oct/2008   rangsima@chiangmai.ac.th   101
Anterior chamber



                             Deep anterior chamber




                             Shallow anterior chamber


Oct/2008   rangsima@chiangmai.ac.th              102
Oct/2008   rangsima@chiangmai.ac.th   103
Hyphema                          Hypopyon




Oct/2008   rangsima@chiangmai.ac.th          104
Coloboma                               Polycoria




Iris Neovascularization                      Aniridia




 Oct/2008         rangsima@chiangmai.ac.th                105
Iridodialysis
  Albinisms




                                          Iris prolapse




Oct/2008      rangsima@chiangmai.ac.th                    106
Pupil



                     Pupil
                     Round
                     Equal
                     React to light
                     Accommodation
Oct/2008     rangsima@chiangmai.ac.th   107
Anisocoria




                         Polycoria and corectopia




 Oct/2008    rangsima@chiangmai.ac.th           108
Leukocoria




Oct/2008         rangsima@chiangmai.ac.th   109
Pupillary Exam
                     • Direct Light
                     • Consensual Light
                     • Swinging Flash Light




Oct/2008      rangsima@chiangmai.ac.th   110
Oct/2008   rangsima@chiangmai.ac.th   111
Relative Afferent Pupillary Defect - RAPD




Oct/2008        rangsima@chiangmai.ac.th   112
RAPD-
           Relative Afferent Pupillary Defect




Oct/2008           rangsima@chiangmai.ac.th   113
Oct/2008   rangsima@chiangmai.ac.th   114
Oct/2008   rangsima@chiangmai.ac.th   115
Cataracts




Oct/2008   rangsima@chiangmai.ac.th   116
Marfan’s Syndrome-Lens subluxation




Oct/2008         rangsima@chiangmai.ac.th   117
Contents
 History Taking
 Ocular Symptomatology
 Visual Acuity Test
 External Eye Examination
    Eye Lids
    Eyeball
    Lacrimal System
    Conjunctiva
 Anterior Segment Examination
    Cornea
    Anterior Chamber
    Iris
    Pupil
    Lens
 Testing of Function of Extraocular Muscles
    Oct/2008          rangsima@chiangmai.ac.th   118
Oct/2008   rangsima@chiangmai.ac.th   119
การตรวจการทางานของกล้ามเนื้อตา
1.Ocular Motility
                     2.Corneal light reflex

3.Cover test
             4.Near point of convergence
  Oct/2008      rangsima@chiangmai.ac.th   120
Six cardinal direction of gaze
1.Ocular Motility




              การตรวจการกลอกตาข้างเดียว = duction
   Oct/2008
                กลอกตาสองข้างพร้อมกัน = version
                        rangsima@chiangmai.ac.th          121
http://www.med.umich.edu/lrc/coursepages/M1/anatomy/html/surface/cardinal/cardinal.html
 Oct/2008                       rangsima@chiangmai.ac.th                             122
2.Corneal light reflex                       Hirschberg test




• The white spots in each              • The main light reflection is
  pupil are actually the                 in the same position in each
  reflection of the light from           eye. Also note the extra light
  the penlight that is being             reflections in both eyes that
  shined in the eyes.                    are due to the reflection of
                                         the ceiling light.
   Oct/2008               rangsima@chiangmai.ac.th                123
• without glasses : left eye corneal light reflection is in the
   outer aspect of her left pupil, and the reflection in her right
   pupil is centered.
 • with glasses both eyes have a symmetrical reflection.
 • This illustrates the importance of keeping the child’s
   glasses on while administering this screening procedure.
Oct/2008               rangsima@chiangmai.ac.th               124
Oct/2008   rangsima@chiangmai.ac.th   125
3.Cover test




            –Alternate Cover Test
            –Cover Uncover Test
 Oct/2008        rangsima@chiangmai.ac.th   126
Alternate Cover Test
    ู้          ่
ให้ผป่วยจ้องไฟทีระยะห่าง 1 ฟุต ให้ผตรวจปิ ดตาผูป่วย สลับกัน
                                     ู้        ้
  ทีละข้าง แล้วสังเกตดูการเคลื่อนทีของตาทีปิด
                                   ่      ่




Oct/2008              rangsima@chiangmai.ac.th                127
ถ้าตาไม่เคลื่อนที่ แสดงว่าตาตรง (orthophoric)
ถ้าตาเคลื่อนทีแสดงว่าตาเข เช่น
              ่                     ตาเคลื่อนที่จากด้านนอก
      เข้าหาตรงกลาง แสดงว่าตาเขนอก
      (exodeviation)
ถ้าตาเคลื่อนทีจากด้านในเข้าหาตรงกลาง แสดงว่า ตาเขใน
                ่
      (esodeviation)
 ถ้าตาเคลื่อนทีจากด้านบนเข้าหาตรงกลาง แสดงว่าตาเขขึ้นบน
                    ่
      (hyperdeviation)
ถ้าตาเคลื่อนทีจากด้านล่างเข้าหาตรงกลาง แสดงว่าตาเขลงล่าง
                  ่
      (hypodeviation)


  Oct/2008                    rangsima@chiangmai.ac.th       128
Cover Uncover Test
    • หลังจากตรวจ alternate cover test แล้ว และพบว่ามี
       ตาเข และต้องการจะแยกว่าตาเขนันเป็ นชนิด ซ่อนเร้น (phoria)
                                         ้
       หรือเปิ ดเผย (tropia)
    • ให้ผตรวจปิ ดตาข้างหนึ่งของผูป่วยแล้วเปิ ดออก และสังเกตการเคลื่อนที่
           ู้                       ้
       ของตา
    • ถ้าผูป่วยนันทราบจากการตรวจ alternate cover test
              ้ ้
       แล้วว่าเป็ นตาเขออกนอก เมื่อเปิ ดตาผูป่วยออกพบว่า ตาเคลื่อนจากด้าน
                                              ้
       นอกเข้าหาตรงกลาง แสดงว่า ตาเขออกนอกนันเป็ นชนิดซ่อนเร้น
                                                    ้
       (exophoria)
    • แต่ถาตาไม่เคลื่อนที่ แต่ยงคงเขออกนอกอยูเ่ ช่นเดิม แสดงว่าตาเขออก
               ้                 ั
       นอกนันเป็ นชนิดเปิ ดเผย (exotropia)
Oct/2008
                 ้         rangsima@chiangmai.ac.th                 129
Oct/2008   rangsima@chiangmai.ac.th   130
4.Near point of convergence



               • ให้ผป่วยจ้องปลายวัตถุเล็ก ๆ ทีเ่ คลื่อนใกล้
                      ู้
                 เข้าหาผูป่วย โดยปกติตาสองข้างจะสามารถ
                         ้
                 มองตาม วัตถุนนเมื่อเคลื่อนใกล้เข้ามา ใน
                                ั้
                 ระยะ ห่าง 5-7 ซม. ถ้าไม่สามารถแสดงว่า
                 เป็ น convergence
                 insufficiency
  Oct/2008     rangsima@chiangmai.ac.th               131
 History Taking
                                                  Contents
    Ocular Symptomatology
    Visual Acuity Test
    External Eye Examination
       Eye Lids
       Eyeball
       Lacrimal System
       Conjunctiva
    Anterior Segment Examination
       Cornea
       Anterior Chamber
       Iris
       Pupil
       Lens
    Testing of Function of Extraocular Muscles
Oct/2008             rangsima@chiangmai.ac.th         132
Any Question!!!!



                                                       Rangsima Poomsawat
                                      http://www.facebook.com/RangsimaPoomsawat
                                                     http://www.slideshare.net/rpoom
                                        http://www.youtube.com/RangsimaPoomsawat
http://www.facebook.com/pages/Nursing-Room-By-Rangsima/109937325743807?v=wall
  Oct/2008                  rangsima@chiangmai.ac.th                       133

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Eye assessment

  • 1. Rangsima Poomsawat Department of Public Health Nursing Faculty of Nursing Chiang Mai University E mail: rangsima@ chiangmai.ac.th http://www.facebook.com/RangsimaPoomsawat http://www.slideshare.net/rpoom http://www.youtube.com/RangsimaPoomsawat http://www.facebook.com/pages/Nursing-Room-By-Rangsima/109937325743807?v=wall Oct/2008 rangsima@chiangmai.ac.th 1
  • 2. Contents 1. History Taking 2. Ocular Symptomatology 3. Visual Acuity Test 4. External Eye Examination 1. Eye Lids 2. Eyeball 3. Lacrimal System 4. Conjunctiva 5. Anterior Segment Examination 1. Cornea 2. Anterior Chamber 3. Iris 4. Pupil 5. Lens 6. Testing of Function of Extraocular Muscles Oct/2008 rangsima@chiangmai.ac.th 2
  • 3. Oct/2008 rangsima@chiangmai.ac.th 3
  • 4. • The purpose of the interviewing a client is to obtain a health history. • Ask about the symptoms or other phenomena associated with the client’s chief problems or concerned and at the same time observes for signs in the client’s physical appearance or behaviors. Oct/2008 rangsima@chiangmai.ac.th 4
  • 5. • Introductory phase – To create a climate of trust to promote interaction – Introduce yourself : your full name, your role **This greeting respectfully acknowledges the clients and conveys your accountability as part of health care team – Describe your purpose of the interview Oct/2008 rangsima@chiangmai.ac.th 5
  • 6. • Working phase – You and the client should both be comfortably seated and facing each other during the interview. – To put the client ease, directly state that the information you obtain will be confidential, recorded in the medical record,and share with those directly involved in the care and treatment plan. – Take some note and complete final record later. – Eye Practitioner may be skillful in communication techniques to enable a client to share life experiences relevant to his health status. Oct/2008 rangsima@chiangmai.ac.th 6
  • 7. Interview Techniques Type of Questions – Opened ended : broad opening statements • Your concern today is….? • Tell me what bring you here today? – Closed ended : requires a response of one or two words,such as yes or no • Age, Marital status, Medication – Directive questions : lead the client to focus on one set of thought • Used in review of system or in evaluating functional health status. • Have you experienced any problem with urination in the past,such as infection ,unusual frequency, urgency, or difficulty urination? – Permission-giving questions • Asks client questions about sensitive area : Sexual transmitted infection • Let a client know that it is all right to speak such things to you. Oct/2008 rangsima@chiangmai.ac.th 7
  • 8. Interview Techniques Use of Silence Short period of silence allow the clients organize their thoughts. During silence period,you can observe the clients emotional state and note nonverbal cues. Silence may also indicate that either you or the client need time to reflect on what was just said. Oct/2008 rangsima@chiangmai.ac.th 8
  • 9. Validating Information From the Interview • Clarification : ask the client to clarify the thought or feeling • Restatement : involves repeating what the client has said using different word. • Reflection : repeat phrase or sentence the client just said. • Confrontation : make the client aware that what you observe is not consistent with he said. • Interpretation : share with the client the conclusion you have drawn from the information you obtained • Summary : summarize the information when terminate interview Oct/2008 rangsima@chiangmai.ac.th 9
  • 10. Nonverbal Communication • Body language : – Body Posture, Facial expressions are indicators of emotional states such as fear anxiety, surprise or joy • Eye contact – Avoid eye contact during interviewing may have anxiety • Interpersonal Distance : vary by the nature or cultural practice • Touch : express appreciation and trust by touch Oct/2008 rangsima@chiangmai.ac.th 10
  • 11. Organization of A History • Introductory Data • Chief complaint • Present illness • Past History • Personal History • Family History • Review of System Oct/2008 rangsima@chiangmai.ac.th 11
  • 12. Introductory Data •Included under general information are the essential facts – Name, Address, Date of birth , Age, Sex – Occupation • Type of work • Industrial hazard Oct/2008 rangsima@chiangmai.ac.th 12
  • 13. Chief Complaint : CC The main reason for which the patient has come to the doctor for advice and help Include a notation of the duration of problem • Blurred Vision **** • Ocular pain (ocular ache) , Burn sensation *** • Discharge • Red eye • Itching • Changes in vision or visual fields • Difficulty reading • Oct/2008 cyst , stye , exophthalmos Etc : rangsima@chiangmai.ac.th 13
  • 14. Example of good statements of CC • “Blurred vision Right eye for 7 days” • “Headache and fever for 6 hours.” • “Vision test needed for work” Oct/2008 rangsima@chiangmai.ac.th 14
  • 15. Greater detail of main symptoms Present Illness :PI • Duration : – How long has this condition lasted? Is it similar to a past problem? If so, what was done at that time? • Onset : sudden or gradually • Severity/ Character – How bothersome is this problem? Does it interfere with your daily activities? – If they are describing pain, ask them to rate it from 1 to 10 with 10 being the worse pain of their life – When describing pain, ask if it's like anything else that they've felt in the past. Knife-like? A sensation of pressure? A toothache? – If it affects their activity level, determine to what Oct/2008 degree this occurs. rangsima@chiangmai.ac.th 15
  • 16. Present Illness : PI • Location/ Radiation : unilateral or bilateral – Is the symptom (e.g. pain) located in a specific place? Has this changed over time? If the symptom is not focal, does it radiate to a specific area of the body? • Pace of illness: Is the problem getting better, worse, or staying the same? If it is changing, what has been the rate of change? • Are there any associated symptoms? If so, what's made it better (or worse)? • Have they tried any therapeutic maneuvers? If so, what's made it better (or worse)? • What do they think the problem is and/or what are they worried it might be? Oct/2008 rangsima@chiangmai.ac.th 16
  • 17. Present Illness : PI • Why today? – This is particularly relevant when a patient chooses to make mention of symptoms/complaints that appear to be long standing. – Is there something new/different today as opposed to every other day when this problem has been present? – Does this relate to a gradual worsening of the symptom itself? Oct/2008 rangsima@chiangmai.ac.th 17
  • 18. Past History : PH • Past Ocular Problem /Trauma / Ocular surgery : repeat , chronic • Herpetic stromal keratitis • Aphakia , Lens Extraction • Visual acuity in the past / Eye glasses • Myopia , Presbyopia , Astigmatism • Past Medical History • Hypertension, Diabetic Mellitus, Thyrotoxicosis • Malaria, Tuberculosis ** • Past Surgical History • Accident and disabling injuries • Hospitalization (including Blood transfusion) Oct/2008 rangsima@chiangmai.ac.th 18
  • 19. Past History : PH • Medications (ocular or other) • Mydriatics Myotics • Steroid • Ethambutol , Quinine, Chloroquine • Epinephrine , silver nitrate • Herbal preparation or nutrition supplement Oct/2008 rangsima@chiangmai.ac.th 19
  • 20. Past History : PH • Allergies/Reactions – Environment :Inhalants Contactants – Food : Ingestants – Medication • Pediatric: – Growth and Development – Immunization Oct/2008 rangsima@chiangmai.ac.th 20
  • 21. Personal History • Habits :Smoking / Alcohol /Caffeine/Drugs • Sexual Activity Oct/2008 rangsima@chiangmai.ac.th 21
  • 22. Family History : FH • Heritable illnesses • Color blindness , Retinoblstoma • Myopia ,Glaucoma • Chronic Disease • DM Hypertension • Communicable diseases(including family Sibling Sex partner) • HIV • TB • Malaria Oct/2008 rangsima@chiangmai.ac.th 22
  • 23. Review of Systems • Health History : – Head and Neck – Thorax and Lung – Heart – Abdomen – Musculoskeletal – Neurological – Mental Oct/2008 rangsima@chiangmai.ac.th 23
  • 24. Contents  History Taking  Ocular Symptomatology  Visual Acuity Test  External Eye Examination  Eye Lids  Eyeball  Lacrimal System  Conjunctiva  Anterior Segment Examination  Cornea  Anterior Chamber  Iris  Pupil  Lens  Testing of Function of Extraocular Muscles Oct/2008 rangsima@chiangmai.ac.th 24
  • 25. Oct/2008 rangsima@chiangmai.ac.th 25
  • 26. Ocular Symtomatology • Visual Symptoms • Non-Visual Symptoms Oct/2008 rangsima@chiangmai.ac.th 26
  • 27. Oct/2008 rangsima@chiangmai.ac.th 27
  • 28. Blurred vision • Monocular, Binocular • Sudden , Progressive • Distance : Near Far • Character • Duration Oct/2008 rangsima@chiangmai.ac.th 28
  • 29. Blindness • VA < 6/60 • VF < 20 degree • Cause – Cataract – Glaucoma • Type – Cortical Blindness – Perceptual Oct/2008 rangsima@chiangmai.ac.th 29
  • 30. Amsler’s Grid Metamorphopsia Oct/2008 rangsima@chiangmai.ac.th 30
  • 31. Visual Symptoms •Micropsia •Macropsia Oct/2008 rangsima@chiangmai.ac.th 31
  • 32. Iridescent Vision Oct/2008 rangsima@chiangmai.ac.th 32
  • 33. Chromatopsia Oct/2008 rangsima@chiangmai.ac.th 33
  • 34. Floater Oct/2008 rangsima@chiangmai.ac.th 34
  • 35. Diplopia Oct/2008 rangsima@chiangmai.ac.th 35
  • 36. Photopsia Photophobia Visual Field Defect Oct/2008 rangsima@chiangmai.ac.th 36
  • 37. Night Blindness Day Blindness Color Blindness Oct/2008 rangsima@chiangmai.ac.th 37
  • 38. Oct/2008 rangsima@chiangmai.ac.th 38
  • 39. Headache Ocular Ache Oct/2008 rangsima@chiangmai.ac.th 39
  • 40. Burning Sensation Foreign Body Sensation Oct/2008 rangsima@chiangmai.ac.th 40
  • 41. Itching Pulling Sensation Oct/2008 rangsima@chiangmai.ac.th 41
  • 42. Red Eye Discharge Oct/2008 rangsima@chiangmai.ac.th 42
  • 43. Dry Eyes Lid Swelling Oct/2008 rangsima@chiangmai.ac.th 43
  • 44. Exophthalmos Discoloration Oct/2008 rangsima@chiangmai.ac.th 44
  • 45. Contents  History Taking  Ocular Symptomatology  Visual Acuity Test  External Eye Examination  Eye Lids  Eyeball  Lacrimal System  Conjunctiva  Anterior Segment Examination  Cornea  Anterior Chamber  Iris  Pupil  Lens  Testing of Function of Extraocular Muscles Oct/2008 rangsima@chiangmai.ac.th 45
  • 46. • Assessment of the eye's ability to distinguish object details and shape, using the smallest identifiable object that can be seen at a specified distance (usually 20 ft. or 16 in.). Oct/2008 rangsima@chiangmai.ac.th 46
  • 47. • Finding normal VA >> – Clarity of cornea anterior body Lena Vitreous Humor – adequacy of macular (central vision) – Functioning of nerve fiber from macula to the occipital cortex Oct/2008 rangsima@chiangmai.ac.th 47
  • 48. For distant vision Oct/2008 rangsima@chiangmai.ac.th 48
  • 49. For Near vision: • Near vision is tested by using a test card and each eye is tested individually. • The card has number of printed paragraphs with print of varying sizes. Each paragraph is described in terms of “points” measuring the body of the print – where a “point” is 1/72 of an inch. • In a common test, N48 is the largest type, and N5 is the smallest, which an unimpaired eye can see, held at a comfortable reading distance, (usually 14 inches), from the eyes. Oct/2008 rangsima@chiangmai.ac.th 49
  • 50. Equipment Oct/2008 rangsima@chiangmai.ac.th 50
  • 51. Oct/2008 rangsima@chiangmai.ac.th 51
  • 52. วัดสายตา Oct/2008 rangsima@chiangmai.ac.th 52
  • 53. Oct/2008 rangsima@chiangmai.ac.th 53
  • 54. Oct/2008 rangsima@chiangmai.ac.th 54
  • 55. Snellen chart • Distance 6 m. or 20 ft. • Without glasses SC 6/24 , 6/36 • with glasses CC 6/9 , 6/9 • With pinholes CC PH 6/6 , 6/6 • Interprete VA (visual acuity) numerator denotes the distance the patient is from the chart letter denominator denotes the distance from the chart at which normal person Oct/2008 rangsima@chiangmai.ac.th 55
  • 56. Visual acuity • 6/6, 6/9, 6/12, 6/18, 6/24, 6/36, 6/60 • 5/60, 4/60, 3/60, 2/60, 1/60 • FC 2 ft, FC 1 ft (finger count) • HM (hand motion) • PJ (projection of light) • PL (perception of light) • NLP (no light perception) Oct/2008 rangsima@chiangmai.ac.th 56
  • 57. VA with pinholes • Improve : R/O refractive error • No improve or worse : R/O Ocular disease SC 6/24 , 6/36 SC 6/12 , 6/9 SC c PH 6/9 , 6/9 SC c PH 6/24 , 6/12 Oct/2008 rangsima@chiangmai.ac.th 57
  • 58. VA Test in Children Oct/2008 rangsima@chiangmai.ac.th 58
  • 59. Oct/2008 rangsima@chiangmai.ac.th 59
  • 60. Contents  History Taking  Ocular Symptomatology  Visual Acuity Test  External Eye Examination  Eye Lids  Eyeball  Lacrimal System  Conjunctiva  Anterior Segment Examination  Cornea  Anterior Chamber  Iris  Pupil  Lens  Testing of Function of Extraocular Muscles Oct/2008 rangsima@chiangmai.ac.th 60
  • 61. • Torch light, Pen light • Magnifier Equipment • Eye pad • Cotton bud • Fluorescine strip • Direct Ophthalmoscope • Topical anesthesia Oct/2008 rangsima@chiangmai.ac.th 61
  • 62. Oct/2008 rangsima@chiangmai.ac.th 62
  • 63. External Eye • Orbit • Eyelid • Eyelash • Lacrimal system • Conjunctiva Oct/2008 rangsima@chiangmai.ac.th 63
  • 64. Anatomy Oct/2008 rangsima@chiangmai.ac.th 64
  • 65. Herpes Zoster Ophthalmicus Ecchymosis Cellulitis - Preseptal Cellulitis - Orbital Oct/2008 rangsima@chiangmai.ac.th 65
  • 66. Exophthalmos Enophthalmos Buphthalmos Lagophthalmos Oct/2008 rangsima@chiangmai.ac.th 66
  • 67. Trichiasis Distichiasis Poliosis Vogt Koyanagi Harada syndrome- Oct/2008 rangsima@chiangmai.ac.th 67
  • 68. Entropion Ectropion Molluscum Contagiosum Xanthelasma Carcinoma Oct/2008 rangsima@chiangmai.ac.th 68
  • 69. Dermatochalasis Blepharochalasis Levator dehiscence Ptosis Oct/2008 rangsima@chiangmai.ac.th 69
  • 70. Hordeolum Chalazion Blepharitis Oct/2008 rangsima@chiangmai.ac.th 70
  • 71. Coloboma Epicanthus Oct/2008 rangsima@chiangmai.ac.th 71
  • 72. Lacrimal System Anatomy Oct/2008 rangsima@chiangmai.ac.th 72
  • 73. Oct/2008 rangsima@chiangmai.ac.th 73
  • 74. Dry Eye Syndrome Tear • Alacrima • Lacrimal Hypersecretion – Hereditary or congenital deficiency or absence of tear secretion. Oct/2008 rangsima@chiangmai.ac.th 74
  • 75. Oct/2008 rangsima@chiangmai.ac.th 75
  • 76. Dacryocystitis Oct/2008 rangsima@chiangmai.ac.th 76
  • 77. Conjunctival Anatomy Oct/2008 rangsima@chiangmai.ac.th 77
  • 78. Oct/2008 rangsima@chiangmai.ac.th 78
  • 79. Oct/2008 rangsima@chiangmai.ac.th 79
  • 80. Oct/2008 rangsima@chiangmai.ac.th 80
  • 81. The Red Eye Conjuncival injection Red eye Circumcorneal or ciliary injection Oct/2008 rangsima@chiangmai.ac.th 81
  • 82. Subconjunctival Hemorrhage Discharge Oct/2008 rangsima@chiangmai.ac.th 82
  • 83. Oct/2008 rangsima@chiangmai.ac.th 83
  • 84. Papilla & Follicle Papillary hypertrophy Cobble stone papillae Oct/2008 rangsima@chiangmai.ac.th 84
  • 85. Chemosis Symblepharon Inflamed Pingueculum Pterygium Oct/2008 rangsima@chiangmai.ac.th 85
  • 86. Betot spot Phlyctenules Oct/2008 rangsima@chiangmai.ac.th 86
  • 87. Oct/2008 rangsima@chiangmai.ac.th 87
  • 88. Oct/2008 rangsima@chiangmai.ac.th 88
  • 89. Oct/2008 rangsima@chiangmai.ac.th 89
  • 90. Foreign Body Oct/2008 rangsima@chiangmai.ac.th 90
  • 91. Contents  History Taking  Ocular Symptomatology  Visual Acuity Test  External Eye Examination  Eye Lids  Eyeball  Lacrimal System  Conjunctiva  Anterior Segment Examination  Cornea  Anterior Chamber  Iris  Pupil  Lens  Testing of Function of Extraocular Muscles Oct/2008 rangsima@chiangmai.ac.th 91
  • 92. Oct/2008 rangsima@chiangmai.ac.th 92
  • 93. Anterior Segment Anatomy Oct/2008 rangsima@chiangmai.ac.th 93
  • 94. Corneal Anatomy Oct/2008 rangsima@chiangmai.ac.th 94
  • 95. Corneal light reflex Oct/2008 rangsima@chiangmai.ac.th 95
  • 96. Megalocornea Arcus senilis Herbert’s pit Corneal Edema Oct/2008 rangsima@chiangmai.ac.th 96
  • 97. Cornea Haze Corneal Abrasion Oct/2008 rangsima@chiangmai.ac.th 97
  • 98. Dermoid cyst Rheumatoid Scleromalacia Perforans Corneal Ulcer Rheumatoid Oct/2008 Corneal Ulceration rangsima@chiangmai.ac.th 98
  • 99. Pannus Foreign Body Oct/2008 rangsima@chiangmai.ac.th 99
  • 100. Blinking reflex Slight Discomfort Lacrimation Oct/2008 rangsima@chiangmai.ac.th 100
  • 101. Oct/2008 rangsima@chiangmai.ac.th 101
  • 102. Anterior chamber Deep anterior chamber Shallow anterior chamber Oct/2008 rangsima@chiangmai.ac.th 102
  • 103. Oct/2008 rangsima@chiangmai.ac.th 103
  • 104. Hyphema Hypopyon Oct/2008 rangsima@chiangmai.ac.th 104
  • 105. Coloboma Polycoria Iris Neovascularization Aniridia Oct/2008 rangsima@chiangmai.ac.th 105
  • 106. Iridodialysis Albinisms Iris prolapse Oct/2008 rangsima@chiangmai.ac.th 106
  • 107. Pupil Pupil Round Equal React to light Accommodation Oct/2008 rangsima@chiangmai.ac.th 107
  • 108. Anisocoria Polycoria and corectopia Oct/2008 rangsima@chiangmai.ac.th 108
  • 109. Leukocoria Oct/2008 rangsima@chiangmai.ac.th 109
  • 110. Pupillary Exam • Direct Light • Consensual Light • Swinging Flash Light Oct/2008 rangsima@chiangmai.ac.th 110
  • 111. Oct/2008 rangsima@chiangmai.ac.th 111
  • 112. Relative Afferent Pupillary Defect - RAPD Oct/2008 rangsima@chiangmai.ac.th 112
  • 113. RAPD- Relative Afferent Pupillary Defect Oct/2008 rangsima@chiangmai.ac.th 113
  • 114. Oct/2008 rangsima@chiangmai.ac.th 114
  • 115. Oct/2008 rangsima@chiangmai.ac.th 115
  • 116. Cataracts Oct/2008 rangsima@chiangmai.ac.th 116
  • 117. Marfan’s Syndrome-Lens subluxation Oct/2008 rangsima@chiangmai.ac.th 117
  • 118. Contents  History Taking  Ocular Symptomatology  Visual Acuity Test  External Eye Examination  Eye Lids  Eyeball  Lacrimal System  Conjunctiva  Anterior Segment Examination  Cornea  Anterior Chamber  Iris  Pupil  Lens  Testing of Function of Extraocular Muscles Oct/2008 rangsima@chiangmai.ac.th 118
  • 119. Oct/2008 rangsima@chiangmai.ac.th 119
  • 120. การตรวจการทางานของกล้ามเนื้อตา 1.Ocular Motility 2.Corneal light reflex 3.Cover test 4.Near point of convergence Oct/2008 rangsima@chiangmai.ac.th 120
  • 121. Six cardinal direction of gaze 1.Ocular Motility การตรวจการกลอกตาข้างเดียว = duction Oct/2008 กลอกตาสองข้างพร้อมกัน = version rangsima@chiangmai.ac.th 121
  • 123. 2.Corneal light reflex Hirschberg test • The white spots in each • The main light reflection is pupil are actually the in the same position in each reflection of the light from eye. Also note the extra light the penlight that is being reflections in both eyes that shined in the eyes. are due to the reflection of the ceiling light. Oct/2008 rangsima@chiangmai.ac.th 123
  • 124. • without glasses : left eye corneal light reflection is in the outer aspect of her left pupil, and the reflection in her right pupil is centered. • with glasses both eyes have a symmetrical reflection. • This illustrates the importance of keeping the child’s glasses on while administering this screening procedure. Oct/2008 rangsima@chiangmai.ac.th 124
  • 125. Oct/2008 rangsima@chiangmai.ac.th 125
  • 126. 3.Cover test –Alternate Cover Test –Cover Uncover Test Oct/2008 rangsima@chiangmai.ac.th 126
  • 127. Alternate Cover Test ู้ ่ ให้ผป่วยจ้องไฟทีระยะห่าง 1 ฟุต ให้ผตรวจปิ ดตาผูป่วย สลับกัน ู้ ้ ทีละข้าง แล้วสังเกตดูการเคลื่อนทีของตาทีปิด ่ ่ Oct/2008 rangsima@chiangmai.ac.th 127
  • 128. ถ้าตาไม่เคลื่อนที่ แสดงว่าตาตรง (orthophoric) ถ้าตาเคลื่อนทีแสดงว่าตาเข เช่น ่ ตาเคลื่อนที่จากด้านนอก เข้าหาตรงกลาง แสดงว่าตาเขนอก (exodeviation) ถ้าตาเคลื่อนทีจากด้านในเข้าหาตรงกลาง แสดงว่า ตาเขใน ่ (esodeviation) ถ้าตาเคลื่อนทีจากด้านบนเข้าหาตรงกลาง แสดงว่าตาเขขึ้นบน ่ (hyperdeviation) ถ้าตาเคลื่อนทีจากด้านล่างเข้าหาตรงกลาง แสดงว่าตาเขลงล่าง ่ (hypodeviation) Oct/2008 rangsima@chiangmai.ac.th 128
  • 129. Cover Uncover Test • หลังจากตรวจ alternate cover test แล้ว และพบว่ามี ตาเข และต้องการจะแยกว่าตาเขนันเป็ นชนิด ซ่อนเร้น (phoria) ้ หรือเปิ ดเผย (tropia) • ให้ผตรวจปิ ดตาข้างหนึ่งของผูป่วยแล้วเปิ ดออก และสังเกตการเคลื่อนที่ ู้ ้ ของตา • ถ้าผูป่วยนันทราบจากการตรวจ alternate cover test ้ ้ แล้วว่าเป็ นตาเขออกนอก เมื่อเปิ ดตาผูป่วยออกพบว่า ตาเคลื่อนจากด้าน ้ นอกเข้าหาตรงกลาง แสดงว่า ตาเขออกนอกนันเป็ นชนิดซ่อนเร้น ้ (exophoria) • แต่ถาตาไม่เคลื่อนที่ แต่ยงคงเขออกนอกอยูเ่ ช่นเดิม แสดงว่าตาเขออก ้ ั นอกนันเป็ นชนิดเปิ ดเผย (exotropia) Oct/2008 ้ rangsima@chiangmai.ac.th 129
  • 130. Oct/2008 rangsima@chiangmai.ac.th 130
  • 131. 4.Near point of convergence • ให้ผป่วยจ้องปลายวัตถุเล็ก ๆ ทีเ่ คลื่อนใกล้ ู้ เข้าหาผูป่วย โดยปกติตาสองข้างจะสามารถ ้ มองตาม วัตถุนนเมื่อเคลื่อนใกล้เข้ามา ใน ั้ ระยะ ห่าง 5-7 ซม. ถ้าไม่สามารถแสดงว่า เป็ น convergence insufficiency Oct/2008 rangsima@chiangmai.ac.th 131
  • 132.  History Taking Contents  Ocular Symptomatology  Visual Acuity Test  External Eye Examination  Eye Lids  Eyeball  Lacrimal System  Conjunctiva  Anterior Segment Examination  Cornea  Anterior Chamber  Iris  Pupil  Lens  Testing of Function of Extraocular Muscles Oct/2008 rangsima@chiangmai.ac.th 132
  • 133. Any Question!!!! Rangsima Poomsawat http://www.facebook.com/RangsimaPoomsawat http://www.slideshare.net/rpoom http://www.youtube.com/RangsimaPoomsawat http://www.facebook.com/pages/Nursing-Room-By-Rangsima/109937325743807?v=wall Oct/2008 rangsima@chiangmai.ac.th 133