THE EIGHT- PART EYE

EXAMINATION

Visual Acuity
External Eye Examination
Ocular Motility
Pupillary Examination
Visual Field Examination
Slit Lamp Biomiscroscopy
Tonometry
Ophthalmoscopy

University of the East Ramon Magsaysay Memorial Medical Center

Department of Ophthalmology
 I. VISUAL ACUITY
Purpose Resources Things to Watch Out For Normal Findings
• To correctly assess • Snellen/ETDRS/E • Literacy • 20/20 for both eyes
patient's far and near Chart • Communication for far vision without
visual acuity for both • Jaeger Chart disability pinhole
eyes • Occluder/Pinhole • Notable Infection • J1+ for both eyes for
• Position patient at a near vision
distance of 20 feet/6
meters

DESCRIPTION

Visual acuity refers to an angular measurement relating testing distance to the minimal object
size resolvable at that distance. The traditional measurement of distance acuity refers to a visual test in
which a target subtends a visual angle of 5 minutes of arc when a subject is 20 feet away from the
target.

The most basic types of vision are the distance and near visual acuity tests. Even though they
test two different aspects of fine-detail central vision, both tests share some conventions, such as the
use of corrective lenses and an established order for testing each eye.

Testing Distance Visual Acuity (for medical students, pre-clinical level)

1. Ask the patient to stand or sit at a designated testing distance (20 feet from a well illuminated
Snellen chart or 4 meters from a ETDRS wall chart)

2. Examine the poorer eye. If there is no poorer eye, the right eye is examined first.

3. Ask the patient to make sure that the occluder is not touching or pressing against the eye.
Observe the patient to make sure there is no conscious or inadvertent peeking.

4. Ask the patient to say aloud each letter or number, or name the picture object on the lines of
successively smaller optotypes, from left to right until the patient correctly identifies only half the
optotypes on a line.

5. Note the corresponding acuity measurement shown on that line of the chart. Record the
acuity value separately with correction and without correction. If the patient misses half or fewer than
half the letters on the smallest readable line, record how many letters were missed. (E.g. 20/40 -2)
Conversely, if the patient reads the next line but does not reach half the letters, record how many
letters were read in excess. (E.g. 20/40 +2)

6. If the patient could not read the biggest optotype line, have the patient come nearer until the
patient can see the biggest optotype line. Record the acuity value, reducing the numerator by the
distance the patient went nearer with (E.g. 15/200 if using a Snellen chart). Continue doing so until the
patient is 5 feet away from the Snellen chart .
 7. If the patient still could not read the largest optotype line 5 feet away, begin having the
patient count the examiners fingers 5 feet away from the patient.

8. If the patient still could not see and count the examiner's fingers, occlude the eye not being
examined with cotton or cloth to ensure that the eye not being examined is fully and properly occluded.
Have the examiner wave his or her hand and ask if the patient could see the examiner's hand
movement. Vary the examination, alternating moving the hand and keeping it still. Make sure that the
examining hand that is waving is not too close as for the patient to feel its presence.

9. If the patient still could not see the examiner's hand, test the patient for Light Projection. To
do this, use a penlight and illuminate the eye being examined and illuminate it from four different
quadrants namely superiorly, temporally, inferiorly, and nasally. Ask the patient if he or she can identify
the direction where the light is coming from and record it accordingly. If the patient can identify all four
quadrants, record it as "good light projection". If the patient could not identify all quadrants, record the
identified quadrants accordingly.

10. If the patient still could not identify the direction where the illuminating penlight is coming
from, illuminate the light directly on the patient's eye and ask the patient if he or she can identify is
there is presence of light. If the patient can identify if there is presence of light, record it as "Light
perception". Otherwise, record it as "no light perception".

11. Repeat steps 3 to 10 on the opposite eye.

12. Record as follows, in feet and corresponding metric equivalent:

Testing Pinhole Visual Acuity (for medical students, pre-clinical level)

1. Position the patient and test the poorer eye first.

2. Ask the patient to hold the pinhole in front of the eye that is to be tested.

3. Instruct the patient to look at the distance chart through the single pinhole

4. Instruct the patient to use small hand or eye movements to align the pinhole to resolve the
sharpest image on the chart.

5. Have the patient read the line with the smallest letters that are legible as determined on the
previous vision test without the use of a pinhole.
 6. Record the Snellen acuity obtained and precede with the abbreviation.

7. There is no need to have the patient come nearer during a pinhole test. If the patient could
not read the chart, record as "not improved on pinhole"

Testing Near Acuity (for medical students, pre-clinical level)

1. Check near vision with and without correction.

2. With the patient wearing the habitual corrective lens for near and the near card evenly
illuminated, instruct the patient to hold the test card at the distance specified on the card (usually 14
inches).

3. Examine the poorer eye or the eye in complaint.

4. Ask the patient to say each letter or read each word on the line of smallest characters that are
legible on the card.

5. Record the acuity value for each eye separately in the patient's chart.

6. Repeat the procedure with the other eye

7. Repeat the procedure with both eyes viewing the test card

8. Record the binocular acuity achieved.

9. If the patient could not read the largest optotype, place "unable to read Jaeger chart"
 II. EXTERNAL EYE EXAMINATION
Purpose Resources Things to Watch Out For Normal Findings
• To assess the • Penlight • Hand hygiene • Negative for masses
adnexa, periorbital • Stethoscope • Contact lens wear • No ptosis
structures and • Notable infection • No lid retraction
anterior segment of • Possibility of • No conjunctival
the eye open/ruptured globe congestion/injection/
hemorrhage
• Clear cornea
• Deep Anterior
Chamber
•Brown iris

DESCRIPTION

The external ocular examination consists of a three-part step-wise sequence that focuses the
examiner's senses on the patient. They include:

1. Inspection
2. Palpation
3. Auscultation

A fixed sequence of examination steps helps ensure that the examiner has covered all anatomic
details and physiologic functions of the external eye.

Inspection

During inspection, the examiner looks for any abnormalities while examining the patient in the
following sequence:
a) Head and face
– bones, muscles, nerves
– Skin
– lymph nodes
– mouth, nose and paranasal sinuses
b) Orbit
c) Eyelids
d) Lacrimal system
e) Globe

Inspect and compare the palpebral fissures and bulbar conjunctiva of both eyes.
Anterior Chamber Depth Estimation

1. Ask the patient to fixate at a far point. Using a penlight, illuminate the eye being examined on
or near the level of the lateral canthus and observe the iris. At the nasal side of the iris, note the amount
of shadow created. A crescent shadow nearer the limbal area on the nasal side denotes a deep
chamber, while a shadow that's nearer the pupil at the nasal side denotes a shallow chamber.

Assessing Facial Nerve Function (for clinical clerks)

1. Ask the patient to squeeze the eyes forcefully and note whether the orbicularis oculi muscles
completely squeeze the eyelids together.

2. Compare the relative strength of both orbicularis oculi muscles by using your fingertips to pry
the eyelids open. The needed force should be the same for both sides.

3. Ask the patient to smile and show his or her teeth. Note the symmetry of the facial
expression.

4. When there is weakness of one side of the lower face, check for a supranuclear lesion by
asking the patient to raise both eyebrows and to wrinkle the forehead. A central facial palsy spares the
forehead and orbicularis oculi while a peripheral lesion often does not.

Assessing Facial Sensation (for clinical clerks)

1. Using your fingertip, tissue paper, or cotton wisp, lightly touch one side of the patient's face
and then the contralateral, corresponding side. Ask the patient to compare the affected side with the
normal side. Repeat for all three trigeminal nerve dermatomes and for the distribution of each principal
sensory nerve.

2. Map the area of reduced sensation.

3. Perform simultaneous testing of both sides if abnormal cortical function is suspected.

Palpation

Feeling for abnormalities involves tactile, proprioceptive, and temperature senses.

The considerate examiner avoids sudden unexpected touches on or around the eyes,
particularly in patients with poor vision.

A screening examination is done routinely as follows:

1. Use the middle fingers to check for pre-auricular lymph nodes.

2. Use the index finger and thumbs to open the eyelids wide apart.
 3. Ask the patient to gaze in different directions to expose most of the ocular surface as you
inspect the globe.

4. Judge and record any mass according to its size, shape, composition, tenderness and
movability.

Auscultation

Auscultation for an orbital bruit is performed by placing the bell of the stethoscope over the
closed eyelids as the patient briefly holds his or her breath. The noise of eyeball movement can be
eliminated by instructing the patient to open the opposite eyelid.

An optical bruit can signify the presence of a carotid-cavenous fistula or an arteriovenous

malformation. On the other hand, a faint rumbling noise heard over the globe is considered normal.
 III. OCULAR MOTILITY
Purpose Resources Things to Watch Out For Normal Findings
• To assess the ocular • Penlight • Hand hygiene • Full on primary,
motility • Fixation target secondary, and tertiary
gazes

DESCRIPTION

Eye movements can be monocular (one eye only) or binocular (both eyes together). Monocular
eye movements are called ductions and six terms are used to describe them:

1. Adduction - movement of the eye nasally

2. Abduction - movement of the eye temporally
3. Elevation - movement of the eye upward
4. Depression - movement of the eye downward
5. Intorsion - nasal rotation of the superior vertical corneal meridian
6. Extorsion - temporal rotation of the superior vertical corneal meridian

Binocular eye movements are described as versions or vergences. Versions are normal binocular
eye movements in the same direction. (example: to the right, to the left, etc.) One muscle of each eye is
primarily responsible for the movement of that eye into a particular field of gaze. These two
simultaneously acting muscles are called yoke muscles, and their movement is said to be conjugate, that
is, they work at the same time to move the two eyes in the same direction. The six positions of gaze in
which yoke muxcles act together are known as the cardinal positions of gaze. They are right and up,
right, right and down, left and up, left, left and down. Vergences on the other hand are normal
disconjugate binocular eye movements in which eyes move in opposite directions.

Below are three examinations that is done to completely assess a patient's extraocular
movements:

• Ductions – examine one eye at a time, covering the eye not being examined.
• Versions – test for extraocular function with both eyes open.
• Vergence – routinely evaluated are convergence (the movement of both eyes nasally), and
divergence (the movement of both eyes temporally).
Diagnostic Positions of Gaze

1. Primary position (straight ahead)

2. Secondary positions (straight up, straight down, right gaze and left gaze)
3. Tertiary positions (up and right, up and left, down and right, and down and left)

Assessing the Ocular Movements

1. Sit facing the patient.

2. Hold fixation target at eye level 10-14 inches in front of the patient with the patient looking at
the primary position (straight ahead).
3. Ask the patient to follow target as you move in the different field of gaze. Elevate the upper
lid to observe down gaze.
4. Note if the amplitude of eye movements is normal or abnormal in both eyes.
 IV. PUPILLARY EXAMINATION
Purpose Resources Things to Watch Out For Normal Findings
• To observe pupillary • Penlight • Note pupillary size in • Equally constricting
reaction for direct, bright light and in pupils for both eyes on
consensual, and ambient light direct, consensual, and
swinging flashlight test • Irregularly shaped pupil swinging flashlight test
• To check the • Previously
integrity of the pharmacologically dilated
pupillary reflex to pupil
direct, consensual
light stimulation

DESCRIPTION

The pupil is the window of the inner eye, through which light passes to reach retinal
photoreceptors. Because of its potential to reveal serious neurologic or other diseases, examination of
the pupil is an important element of a thorough ophthalmic evaluation.

Pathologic disorders can alter the size, shape, and location of the pupil, as well as the way the
pupil reacts to light and near-focus stimulation.

Performing the Light-Reflex Test (For medical students, pre-clinical level)

1. Under dim room illumination, ask the patient to fixate a target a few degrees above midline
to view the brown pupil better.

2. Shine a bright hand-held light directly into the right eye by approaching it from the side or
from below. Do not stand in front of the patient or allow the patient to look directly at the light, which
would stimulate the near reflex and preclude accurate light-reflex testing.

3. Record the direct pupillary response to light in the right eye in terms of the briskness of the
response, graded from 0, indicating no response, to 4+, indicating a brisk response.

4. Repeat steps 1-3 for the left eye.

5. Repeat steps 1 & 2 in the right eye, observing for the consensual reflex by noting the response
to the light of the non-illuminated (left) pupil. The rapidity of the response and change in pupil size
should normally be equivalent to that seen in the direct light reaction and is graded on the same
numeric scale.

6. Repeat steps 1,2, and 5 in the left eye.

Performing the Swinging Flashlight Test (For medical students, pre-clinical level)

1. Under dim room illumination, ask the patient to fixate a target a few degrees above midline
to view the brown pupil better.

2. Shine a bright hand-held light directly into the right eye by approaching it from the side or
from below. Do not stand in front of the patient or allow the patient to look directly at the light, which
would stimulate the near reflex and preclude accurate light-reflex testing.

3. Swing the flashlight below the nose (for uniformity of movement) towards the other eye and
observe the pupilary response of the left eye.

4. Repeat steps 1-3 for the left eye.

5. Swing the flashlight every three seconds several times to observe pupillary response to direct
light stimulation. A dilating pupil with direct stimulation may indicate an optic nerve pathology, or
severe macular problem.
 V. VISUAL FIELD EXAMINATION
Purpose Assessment Checklist Things to Watch Out For Normal Findings
• To test for abnormal • Proper positioning • Patient maintains • No gross visual field
blind spots • Amsler Grid fixation on the defect
•To grossly examine examiner's nose
visual fields • Examiner should
ensure patient's eyes are
not wandering

DESCRIPTION

The visual field is that portion of a subject's surroundings that is visible at any one time. The
visual field properly includes central fixation, conventionally measured by visual acuity tests, and
extrafoveal (or peripheral) vision. Central fixation, or visual acuity, and the visual field are tested in
different-ways and provide information on different aspects of visual function. Visual field testing
measures sensitivity, the ability to detect light thresholds at different locations. An abnormal field can
indicate a problem in the retina, optic nerve, or visual pathway.

The visual fields are routinely screened with the confrontation fields test. If macular disease is
suspected to be causing a central field visual field defect, a device called an Amsler grid is used to test
the central area of each eye's visual field. If a visual defect is detected by screening, further evaluation is
conducted by manual or automated procedures known as perimetry. For our purposes, we shall focus
mainly on the screening procedures.

Performing the Confrontation Fields Test (for medical students, pre-clinical level)

Test Set-up

1. Seat the patient and make sure the eye not being tested is occluded.

2. Seat yourself facing the patient at a distance of about 1 meter. The examiner closes the eye
that mirrors the patient’s eye that is occluded (ex. If the patient closes his/her left eye, the examiner
closes his right eye)

3. Ask the patient to fixate on your nose.

Check for Scotoma

4. While the patient is fixating on your nose, ask the patient if there are any missing parts on the
examiner's face to detect any central scotoma.

5. Hold your hands stationary midway between yourself and the patient in opposite quadrants
about 30° from central fixation. Extend your fingers on one hand on the temporal hemifield of the
monocular field, asking the patient if they see movement. Repeat the exam again on the nasal hemifield,
testing at least two times per quadrant. Note if there are any abnormal findings such as the patient not
being able to recognize finger movement. You may test both nasal and temporal fields simultaneously.
Repeat the same steps, this time testing for 4 quadrants and record the findings accordingly.

a) Test patients who have marked visual loss by waving your hand in each quadrant individually
and asking if the patient perceives the motion. With patients who can only perceive light, test in each
quadrant individually for the ability to correctly determine the direction of light projection by pointing a
penlight toward the pupil while keeping the patient's other eye completely occluded.

b) Test young children with a finger-mimicking procedure. First teach the child to hold up the
same number of fingers as you do, then conduct the test as usual.

Diagram the Confrontation Field

If an abnormality is detected, sketch a 360° visual field chart, labeled for right and left eye and
temporal and nasal field, and plot the visual field as the patient sees it. Record a failure to detect an
abnormality as "no defect to finger confrontation"

Performing the Amsler Grid Test

Test Set-up

1. With the patient wearing appropriate reading spectacles or trial lenses for near correction,
ask the patient to hold the testing grid perpendicular to the line of sight, approximately 36 cm (14
inches) from the eye.

Check for Scotoma

2. Examine the BETTER EYE first and occlude the eye not examined.

3. Ask the patient to fixate steadily at the central spot of the grid.
 4. Ask the patient whether all lines are straight and all intersections are perpendicular and if any
areas of the grid appear distorted or missing.

Diagram the Test Result

5. Have the patient draw the area of visual distortions or loss on a reprinted pad which has black
lines on a white background. Be sure to note the eye being tested and the date. Test both eyes and
record the results whether abnormal or not.

VI. SLIT LAMP BIOMICROSCOPY

(for residents)

The slit lamp biomicroscope is a unique instrument that permits magnified examination of
transparent or translucent tissues of the eye in cross-section. The slit-lamp enhances the external
examination by allowing a binocular, stereoscopic view, a wide range of magnification, and illumination
of variable shapes and intensities to highlight different aspects of ocular tissue.

The slit lamp is indispensible for the detailed examination of virtually all tissues of the eye and
some of its adnexae. It is routinely used for examination of the anterior segment, which includes the
anterior vitreous and those structures that are anterior to it.
 VII. DIGITAL TONOMETRY
Purpose Assessment Checklist Things to Watch Out For Normal Findings
• Gross measurement • Hand hygiene • Infectious eye disease • Firm
of IOP (wear gloves)

• Contraindications:
- Trauma or suspicion of
open globe injury
- History of recent eye
surgery
- Contact lens wear

DESCRIPTION

Tonometry is the measurement of intraocular pressure (IOP). It is performed as part of a

thorough ocular examination to help detect ocular hypertension and glaucoma and to detect ocular
hypotony (low IOP) in conditions such as iritis and reinal detachment.

By convention, IOP is measured in millimeters of mercury (mm Hg ). Although there is no strict

cut-off between normal and abnormal intraocular pressures, most people have lOPs between 10 and 21
mm Hg.

Performing Digital Tonometry (for medical students, pre-clinical level)

Although not a device per se, the examiner's fingertips may be used to indent the globe and
roughly estimate intraocular pressure.

Estimating IOP by digital pressure on the globe may be used with uncooperative patients or in
the absence of instrumentation, but it may be inaccurate even in very experienced hands. In general,
digital estimation of IOP is only useful for detecting large differences between the patient’s eyes.

1. Instruct the patient to look down as the examiner gently rests the forefingers of both hands
and insinuate both fingers between the superior orbital rim and superior aspect of the patient‘s globe.
Make sure that the patient does not close his eyes during the examination to prevent inadvertent
trauma to the cornea since the patient's eyeballs roll upwards when the eyelids are shut.

2. For added stability, the examiner may rest his other fingers gently on the patient's forehead
while the .examination is being performed.

3. The examiner gently and alternately depresses both forefingers on the globe while assessing
the tone. [Report the findings as soft, firm, or hard. A normotensive eye, or firm eye, roughly
approximates the tone of the tip of the nose, an eye with elevated pressure, described as hard,
approximates the tone of the glabella, and a hypotensive eye , described as soft is similar in tone to that
of the lips.

4. Repeat the same procedure on the other eye.

 VIII. DIRECT OPHTHALMOSCOPY
Purpose Assessment Checklist Things to Watch Out For Normal Findings
• To examine the • Direct • Familiarize yourself • Symmetric
posterior pole Ophthalmoscope with the ophthalmoscope • Cup disc ratio less
• Perform in dim light • High magnification than 0.5
• Proper positioning (15x) with small field of • 2:3 AV Ratio
view, hence lower
expectations as only a
small part of the retina
will be seen
• Do not come in contact
with the patient's eye
• Active infection

DESCRIPTION

Examination of the eye posterior to the ciliary body and lens is important in assessing overall
ocular health and in diagnosing and monitoring specific optic nerve, retinal, neurologic and systemic
disorders. Ophthalmoscopy is the examination of the posterior segment of the eye, performed with an
instrument called the ophthalmoscope. The posterior segment examination, also sometimes referred to
as the fundus examination, is usually performed with the patient's pupil pharmacologically dilated and
therefore follows pupillary examination. The bright lights that are used also mean that ophthalmoscopy
should succeed visual acuity measurement.

The direct ophthalmoscope is a handheld instrument that consists of a handle and a head with a
light source, a peephole with a range of built-in dial-up lenses and filters, and a reflecting device to aim
light into the patient's eye. It has a magnification of 15x and provides an erect, virtual image of the
retina. Its field of view is about 5 degrees and it does not provide stereopsis.

Performing Direct Ophthalmoscopy (for medical students, pre-clinical level)

1. Direct ophthalmoscopy is performed with the eye that corresponds to the eye being
examined, putting the examiner cheek to jowl with the patient.

2. Instruct the patient to fixate at a distant point and not on the instrument light.

3. Adjust the light intensity to avoid papillary constriction at the start of the examination.

4. Focus the ophthalmoscope by twirling the dial for the millidisc at zero. The optimal focusing
lens depends on the patient's refractive error, the examiner's refractive error and the examination
distance.

3. Check the patient's red reflex for both eyes and see if it is homogeneously seen. Report it as
good, dull, or if there is an absence of the red orange reflex.
 4. Approach the patient slowly. The instrument is steadied against the patient's face by resting
the ulnar border of the hand holding the instrument against the patient's cheeks while the thumb of the
free hand raises the upper eyelid.

5. Change the millidisc accordingly once some of the structures are seen for a clearer view. Note
if the media is clear, hazy, or if the posterior pole could not be seen. Once the vessel structures are seen,
slowly trace the vessel nasally until the optic nerve can be seen. Take note and describe the following:

• The optic nerve cup size, color, and the disc borders
• The vertical cup-disc ratio and if there is venous pulsation
• The Neuro-retinal rim thickness and color
• Take note of the arterio-venous ratio beginning at second branching fo the superior and
inferior arcades
• Presence or absence of any haemorrhages or exudates

6. Examine the macula/fovea last.