Examining the eye
Learning outcomes
To be competent in the performance and documentation of the
following components of the ophthalmic examination:
Visual acuity
Eye movements
Cover test for strabismus
Pupillary reactions
Visual fields by confrontation
Trigeminal nerve function
External eye examination
Internal eye examination
Visual acuity measurement
Patient positioned 6m from Snellen chart
Measure each eye separately using:
Occluder
Up-to-date distance glasses
Start at the top and read down
Record lowest line read
Vision recorded as:
Numerator / denominator
Distance from chart / lowest line read
6/…
Visual acuity measurement
6/6 = good
6/60 = bad
CFs, HMs, PL = worse
Use pinhole if VA <6/9 unaided
logMar vision = decimal
1.0 = 6/60
0.0 = 6/6
Extraocular movements examination
1. Observe at rest
Abnormalities/deviations
Corneal light reflections
Altered head position
Extraocular movements examination
2. Pursuit movements
Follow target (light/…)
9 positions of gaze - double H pattern
Restrictions? Diplopia?
3. Convergence
Right Right Left Left
Eyes move in opposite directions (inwards)
superio inferior inferior superio
r oblique oblique r
rectus
Pupils constrict rectus
Right Right Left Left
latera media medi latera
l l al l
rectu rectus rectu rectus
s s
Right Right Left Left
inferior superio superio inferior
rectus r r rectus
oblique oblique
Cover test
Target & occlude
1. Occlude one eye observe the uncovered
2. Remove the occluder observe the occluded
Repeat for both eyes
Repeat for near & distance
Pupillary examination
1. Observe pupil size & symmetry
2. Determine direct response
Patient fixates on distant target
Light source brought in from the side
Hand on nose bridge if needed
3. Determine consensual response
Swinging flashlight test
Relative afferent pupillary defect
Visual field examination
Confrontation VF test = Donders visual field test
Sit opposite at arms length
Cover one eye and instruct patient to cover opposite eye
Patient fixated on nose/open eye
Hold different number fingers in each of the 4 quadrants *
Patient is asked to identify number of fingers
Repeat in other eye
* Or hand/finger movements going inwards
Trigeminal nerve
CN V
Both sensory and motor function
3 subdivisions (branches)
Ophthalmic (V1): sensory
Maxillary (V2): sensory
Mandibular (V3): sensory and motor
Trigeminal nerve
Sensory assessment:
explain sensations you are going to assess (e.g.
light touch/pinprick) to the patient by
demonstrating on their sternum/hand for reference
Ask the patient to close their eyes and say ‘yes’
each time they feel you touch their face.
Assess the sensory component of V 1, V2 and V3 by
testing light touch and pinprick sensation across
regions of the face supplied by each branch
You should compare each region on both sides of
the face
Trigeminal nerve
Motor assessment:
Inspect the temporalis (located in the temple
region) and masseter muscles (located at the
posterior jaw) for evidence of wasting.
Palpate the masseter muscle (located at the
posterior jaw) bilaterally whilst asking the
patient to clench their teeth to allow you to
assess and compare muscle bulk.
Ask the patient to open their mouth whilst you
apply resistance underneath the jaw to assess
the lateral pterygoid muscles.
External eye examination
Outside-in
1. Orbits
Symmetry
Masses
skin
2. Lids
Symmetry
Masses
(mal)position
Lashes
eversion
Anterior segment examination
Use pen torch
1. Conjunctiva & sclera
Colour
Appearance
texture
2. Cornea
Opacities
Staining with fluorescein
3. Anterior chamber
Aqueous
Pupils
iris
Intra-ocular pressure
Applanation tonometry
Instil topical anesthetic and fluoresceine
Apply tonometer to cornea
Align prisms
Read dial
Alternatives
Digital palpation
Hand-held tonometer
Direct ophthalmoscopy
1. Red reflex
Stand back 0.5m
Shine light into both eyes
Equal red reflex?
Direct ophthalmoscopy – optic disc
Ask patient to look straight ahead
Approach with red reflex in sight
Aim for nasal to midline
Asses 3 C’s:
Colour
Countour
Cup:disc ratio
Direct ophthalmoscopy – blood vessels
Bigger vessels always lead to the disc
Asses:
Tortuosity
crossings
Direct ophthalmoscopy - retina
Macula
Temporal from the disc
Slightly duskier than rest of retina
Quadrants
Patient looks up-down-left-right
Abnormalities:
Hemorrhage
Exudate
Oedema
Scarring
mass
Direct ophthalmoscopy - technique
Important technique to master
Patients left eye your left eye
1. Turn on and look for red reflex
2. Forward until into focus
3. fine tuning by moving towards/away from patient
Practice, practice, practice
Ocular imaging
Perimetry
Ultrasound
Fluorescein angiography
OCT and OCT-A
Automated perimetry
Visual field analysis
Patient compared to normal
Outcome in grey-black scale
Uses
Glaucomatous field loss
Neurological field loss
Ocular ultrasound
Non-invasive
Useful with no retinal
view
Uses:
Vitreous hemorrhage
Retinal detachment
IOFB
Choroidal mass
Fluorescein angiography
Fluorescent dye injected i.v. – antecubital vein
Series of photographs to assess progress though retinal circulation
Stages
Pre-arterial (choroidal flush)
Arterial
Arteriovenous
Venous#
Late
Side effects
Yellow skin/urine
Nausea and/or vomiting
Hypersensitivity (rare)
Fluorescein angiography
Patetrns
Hyperfluorescence
leakage
Hypofluorescence
Ischemia, masking
Abnormalities
Ischemia
New vessels
inflammation
Optical coherence tomography (OCT)
Low-coherence interferometry
= back-scattered light
Cross sectional imaging of
retina and optic disc
Structural images
High resolution
Retina
Optic disc
angiography
OCT uses
Retina & macula:
ARMD
Diabetic eye disease
Vascular occlusions
Diagnosis & follow up
OCT uses
Optic disc:
Glaucoma
Measurement and follow up RNFL
OCT angiography
Non invasive
Detects RBC motion
Differentiates the 4
vascular layers
OCT angiography
Ischemia
Fovea avascular zone
Macula
New vessels
Intraretinal
Subretinal/choroidal
