Patient History and Ophthalmic Examination Techniques Flashcards

A 58-year-old patient reports intermittent monocular visual loss lasting 2–10 minutes in the right eye, described as a 'curtain coming down from above.' The episodes resolve completely. Which historical detail is MOST critical to document next to differentiate amaurosis fugax from other transient monocular vision loss?

Answer: The presence of associated ipsilateral carotid bruit or cardiovascular risk factors

Amaurosis fugax (transient monocular blindness) is classically caused by emboli from carotid artery disease or cardiac sources. Documenting cardiovascular risk factors (hypertension, hyperlipidemia, smoking, atrial fibrillation) and the presence of a carotid bruit is critical because it determines urgency and directs the workup toward vascular imaging. The 'curtain' description is already classic for retinal ischemia; the vascular history distinguishes a sight- and life-threatening embolic event from benign etiologies like vasospasm.

During binocular indirect ophthalmoscopy, the examiner notices a subtle retinal lesion that appears to shift position relative to surrounding structures as the condensing lens is tilted. This phenomenon most likely indicates the lesion is:

Answer: Elevated above the plane of the retina (e.g., preretinal membrane)

Parallax shift during BIO is used to assess the three-dimensional position of a lesion. A lesion that shifts in the same direction as lens tilt is elevated above the retinal plane (e.g., a preretinal membrane, vitreous opacity, or elevated tumor). Flat RPE lesions and subretinal/choroidal lesions do not exhibit this parallax movement. Understanding this optical principle helps differentiate vitreoretinal pathology without additional imaging.

A technician is documenting a patient's medication history and notes they are taking topical timolol 0.5% BID for glaucoma. The patient also reports new-onset exercise intolerance and cold extremities. The MOST appropriate action is to:

Answer: Record the symptoms in the history and flag them for the physician, as they may represent systemic beta-blockade

Topical beta-blockers like timolol have measurable systemic absorption via nasolacrimal drainage, bypassing first-pass hepatic metabolism. This can produce clinically significant systemic beta-blockade including bradycardia, bronchospasm, and peripheral vascular symptoms such as cold extremities and exercise intolerance. The technician's role is to accurately document these symptoms and flag them for the physician — not to modify the treatment regimen, which is outside the technician's scope. Dismissing the symptoms is dangerous.

When performing the cover-uncover test on a patient with a suspected phoria, the examiner observes that the UNCOVERED eye moves to pick up fixation each time the cover is removed. This finding is BEST interpreted as:

Answer: A phoria, because dissociation by the cover revealed a latent deviation that must be refixated on removal

In the cover-uncover test, movement of the UNcovered eye upon removal of the cover indicates a phoria (latent deviation). The cover dissociates fusion, allowing the deviated eye to drift; when the cover is removed and binocular vision is restored, the previously covered eye must re-fuse, but the UNCOVERED eye moving to refixate is the telltale sign. If the covered eye moved when the cover was placed, that would indicate a tropia. This distinction is subtle and commonly confused on advanced exams.

A patient with known asteroid hyalosis presents for a routine dilated exam. During direct ophthalmoscopy, the optic disc appears hazy and difficult to evaluate clearly. The MOST appropriate next step to obtain an adequate disc view is:

Answer: Switch to binocular indirect ophthalmoscopy with a 20D condensing lens to use a wider beam and stereoscopic view

Asteroid hyalosis consists of calcium-lipid spherules suspended in the vitreous that cause significant light scattering, especially with the coaxial illumination of direct ophthalmoscopy. Binocular indirect ophthalmoscopy, with its off-axis illumination and wider field, is far superior for viewing the fundus through media opacities like asteroid hyalosis. Increasing the diopter on direct OPH addresses refractive error, not media scatter. A second mydriatic is unnecessary and blinking does not redistribute asteroid bodies.

During Goldmann applanation tonometry, the examiner observes that the two fluorescein semicircles are very wide (thick mires) and the inner edges barely touch at the correct pressure reading. The MOST likely cause of this finding is:

Answer: There is an excess of fluorescein in the tear film, or the tear meniscus is too large

Goldmann applanation tonometry accuracy depends on correctly calibrated mire width. Thick, wide mires indicate excessive fluorescein or a large tear meniscus, which artificially INCREASES the IOP reading because the surface tension of the excessive tear film pulls the prism forward, requiring more pressure to achieve applanation. Thin/narrow mires indicate insufficient fluorescein and lead to falsely LOW readings. Lid squeezing affects IOP by compressing the globe. Rotational misalignment of the prism is corrected for corneal astigmatism >3D but does not affect mire width.