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Elements of an eye exam, correct tools are critical to the internists diagnosis of common eye disorders

BOSTON ─  In a packed meeting room, Lynn K. Gordon, MD, PhD, presented her update on what she calls “office ophthalmology” here at the ACP Internal Medicine meeting.

“History is the most important thing you can master … in any field, in any part of your daily practice of medicine, in particular with eye disease,” Gordon said. “If you listen to the patient, like every other organ in the body, the eyes will try to tell you where to go and what type of diseases to think about.”

She said screening patients who are at high risk is important, particularly patients with diabetes who can benefit from preventative and early treatment of diabetic retinopathy and age-related macular degeneration.

“We now have many drugs that can reverse vision loss in certain circumstances, but [ophthalmologists] need to screen them ahead of time to see when they are getting into trouble [and] try to stop the disease’s track,” she said.

She also made a plea to the audience to think hard before prescribing topical steroids.

“You can get into trouble with topical steroids,” Gordon said. “That 1 out of 100 is going to be a heartache for you and for your patient.” If you think use of topical steroids is warranted, she suggested to refer your patient to an ophthalmologist.

5-minute exam

Gordon described her recommended “5-minute screening exam.”

Measure visual acuity and conduct a penlight exam, she said. During the penlight exam, an internist should assess pupils and ocular alignment; examine lids and adnexa; examine the ocular surface; assess the anterior chamber depth; and perform confrontation visual fields, although they are only valuable in absolute defects, she said.

Finally, at this time, direct ophthalmoscopy is an important part of the exam; however, in 10 years, Gordon’s hope is that a non-mydriatic fundus camera will eventually replace the ophthalmoscope because it provides a superior view of the retina and optic nerve.

What’s in your pocket?

An internist should have a near or distance vision card, a pinhole, and a penlight.

She also said to have mydriatic dilating drops on hand. “Don’t be afraid to dilate the pupils to see the back of the eye, if you really need to see the back of the eye.” The 2.5% Neo Synephrine (Bayer Healthcare LLC) does not affect a patient’s reading vision, but will dilate the pupils enough “to get a glimpse,” she said.

Gordon said to also have topical anesthetic on hand to view corneal abrasions when a patient is unable to open their eye, but warned that it should not be given too often as it is toxic to the epithelium.

Finally, she said to have fluorescein strips to test for herpes keratitis and corneal abrasions.

Gordon pointed out red flags in history or examination that should prompt an internist to refer to an ophthalmologist. – by Joan-Marie Stiglich, ELS

Reference:

Gordon LK. Common Eye Disorders for the Internist. #SS003. Presented at: ACP Internal Medicine Meeting; April 30-May 2, 2015; Boston.

Disclosure: Gordon reports no relevant financial disclosures.