PCD Notes, P Shaw O.D.

2006

Week #7, October 16, 06

Examination of the External Eye

General Symmetry and Ocular aAignment

Is there a head tilt to the right or left? (torticollis) If so then there is

likely an uncorrected vertical phoria

do the eyes seem especially prominent? (exophthalmos = Abnormal

protrusion of the eyeball)

Cover test

The first part of this test is the unilateral cover test. While wearing your corrective eyewear, you
will be asked to focus on a letter of the distance eye chart. The optometrist will then cover your
right eye while watching for a movement of the left eye. Upon removing the occluder, the opto-
metrist will wait for a few seconds to allow your eyes to return to equilibrium then will proceed by
covering the left eye. If the eye not being covered moves to fixate the target (with both eyes open
one eye is not aimed at the point of interest) that eye was not being used. This is referred to as a
strabismus.

The alternating cover test is very similar to the unilateral cover test but the main difference is that
the occluder is switched from one eye to the next. If the eye just uncovered moves this is called a
phoria. This means that in the resting position both eyes are not aimed at the target. Con-
sequently, you must use effort to keep both eyes fixated on the target. This can cause eye strain
and headaches. Prisms in your spectacles or visual training may be required.

Unilateral: Cover left eye, watch the right for movement, uncover
repeat for right. (If movement then strabismus)
Alternating: Alternate fixation by moving cover from left to right to left
etc. (observe deviation phoria if not also strabismus)

Penlight Pupil reflection

Should be about 0.5mm nasally displaced, infants with pseudo
esotropia due to an epicanthal fold can be diagnosed with this
(Hirschberg test)

Eye motility
The doctor will ask you to focus on a near target (most likely their finger) and follow it as he/she
traces a broad letter "H." This tests the ability of your eyes to follow the target. It will indicate any
problem with the nerve supply to your eye muscles or problems with the muscles themselves.

Look for equal and full excursions in the six principle directions of gaze;
dissociate the patient’s images with a card to better isolate long
standing dysfunction. Nystagmus is a small angle high frequency (1-3
per second) eye tremor common with congenital vision impairment.
PCD Notes, P Shaw O.D. 2006

Eyelids

Examine Lashes and lid aposition to the eye (entropian in, ectropian
turned away), do the eyes close completely (not = lagophthalmos) ?

Do the lids appear puffy?

Are lashes aligned, clean ? Lid margin pink, red white? Crustiness is
present with blepharitis.

Pupil responses,

In a moderately dark room shine the light in one eye and assess the
pupil reaction for both the direct and consensual response. They should
be equal.

Swinging Flashlight test alternately (period about one second)

illuminate each pupil, if an eye dilates upon illumination then that
optic nerve is suspect! That means that the direct response is weaker
than the consensual.

Differences in pupil size (anisocoria) are of little interest as long as

the reflexes are normal.

Is the pupil black or grey (cataract)

Cornea

With a strong light in a dark room examine for white patches that
could, in association with symptoms of pain or discomfort indicating
active inflammation or an abrasion.

Arcus Senilis, a white circular cholesterol deposit within the cornea

just inside the corneal limbus, common in older patients.

Visual Acuity: How we do it!

This is performed using the familiar chart with rows of letters. You will be asked to read progress-
ively smaller rows of letters until they become indistinguishable. Even if you have to guess, try to
make out the smallest letters possible to help aid the eye care practitioner in obtaining a good
idea of your visual acuity. If the doctor reports that you have 20/20 vision, you can see a __ inch
letter at a distance of 20 feet. If you have for example, 20/40 vision, this indicates that what you
PCD Notes, P Shaw O.D. 2006

can read at 20 feet can be read by a normal eye at 40 feet. In addition to the distance visual test,
a similar near vision test will probably be conducted.

Visual acuity tests are used to evaluate eyesight. Several types of visual acuity tests may be
used.

• The Snellen test checks your ability to see at distances. It uses a wall chart that
has several lines of letters. The letters on the top line are the largest; those on the
bottom line are the smallest. See an illustration of a Snellen chart .
o You will stand 20 ft(6 m) from the chart and be asked to cover one eye and
then read the smallest line of letters you can see on the chart. If you are
unable to cover your eye, an eye patch will be placed over your eye.
o Each eye is tested separately and then together. You may be given a
different chart or asked to read the lines backward to make sure that you
did not remember the sequence of letters from the previous test.
o If you wear glasses or contacts, you may be asked to repeat the test on
each eye while wearing them.
o Let your doctor know if you have trouble reading the letters on one side of
the line, or if some letters disappear while you are looking at other letters.
You may have a visual field problem and visual field tests may be needed.
• The E chart tests the vision of children and people who cannot read. The E chart is
similar to the Snellen chart in that there are several lines, but all of the lines contain
only the letter E in different positions. The top line is the largest and the bottom line
of Es is the smallest. You will be asked to point to the direction of the E. Similar
charts use the letter C or pictures. These charts are also available in a handheld
card. See an illustration of an E chart .
• The Near test uses a small card containing a few short lines or paragraphs of
printed matter to test your near vision. The size of the print gradually gets smaller.
You will be asked to hold the card about 14 in.(36 cm) from your face and read
aloud the paragraph containing the smallest print you can comfortably read. As with
the Snellen test, each eye is tested separately and then together, with and without
corrective lenses. This test is routinely done after age 40, because near vision
tends to decline as you age (presbyopia).

If you cannot read any of the letters or print on these charts because of poor vision, your visual
acuity will be tested by other techniques, such as counting fingers, detecting hand movements, or
distinguishing the direction or perception of light sources (such as room light or a penlight held up
close to the face).

Visual acuity tests usually take about 5 to 10 minutes. They may be performed by a nurse, a
medical assistant, an ophthalmologist, an optometrist, a teacher, or some other trained person.
Testing may be done at a doctor's office, school, workplace, health fair, or elsewhere.

Reasons for doing it:

• To monitor an eye problem, such as diabetic retinopathy.

• To determine if you need glasses or contact lenses to improve your vision.
• After an injury to the eye.
• When you obtain or renew your driver's license or for some types of employment.
PCD Notes, P Shaw O.D. 2006

A healthy eye can resolve detail of objects down to about1minute or

arc, that is 1/60
of a degree.

Snellen acuity notation is a fraction 20/20, 20/30 etc.

The numerator of the fraction in 20/30 is the test distance 20 this is

the test distance that Dr. Snellen recommended over 100 years ago.

The denominator (30 in this example) is the letter size that the patient
read. He read the 30 foot standard letter at a distance of 20 feet (not
as good).

The 30 foot letter would correspond to a resolution of 1 minute of arc

at 30 feet but at 20 feet that would be a fraction (30*1minute)/20= 1.5
minutes of arc.

We always resolve the acuity to a numerator of 20 feet or 6 meters.

10/50 = 20/100 = 6/30 These are all the same!

Examination of the Internal Eye

Ophthalmoscopy:

Ophthalmoscopy is a test that allows a health professional to see inside the back of the eye
(called the fundus) and other structures using a magnifying instrument (ophthalmoscope) and a
light source. It is done as part of an eye examination and may be done as part of a routine
physical examination.

The fundus contains a lining of nerve cells (the retina), which detects images seen by the clear,
outer covering of the eye (cornea). The fundus also contains blood vessels and the optic nerve.
See an illustration of the structures of the eye .

There are two types of ophthalmoscopy.

• Direct ophthalmoscopy. Your health professional uses an instrument about the

size of a small flashlight with several lenses that can magnify up to about 15 times.
This type of ophthalmoscopy is most commonly done during a routine physical
examination.
• Indirect ophthalmoscopy. Your health professional wears a light attached to a
headband and uses a small handheld lens. Indirect ophthalmoscopy provides a
wider view of the inside of the eye and allows a better view of the fundus even if the
lens is clouded by cataracts.

Ophthalmoscopy is done to:

• Detect problems or diseases of the eye, such as cataracts.

PCD Notes, P Shaw O.D. 2006

• Help diagnose other conditions or diseases that damage the eye.

• Evaluate symptoms, such as headaches.
• Detect other problems or diseases, such as head injuries or brain tumors.

Your health professional may use eyedrops to widen (dilate) your pupils. This makes it easier to
see the back of the eye. The eyedrops take about 15 to 20 minutes to dilate the pupil fully. Your
health professional may also use eyedrops to numb the surface of your eyes. Tell your health
professional if:

• You or anyone else in your family has glaucoma.

• You are allergic to dilating or anesthetic eyedrops.

You may have trouble focusing your eyes for several hours after the test. You may wish to
arrange to have someone drive you home after the test. You also will need to wear sunglasses
when you go outside or into a brightly lit room.

Ophthalmoscopy

Normal: • All of the structures inside the eye appear normal. See an illustration of a
normal retina as seen through an ophthalmoscope.

Abnormal: • Detached retina

• Swelling of the optic nerve (papilledema)
• Optic nerve damage caused by glaucoma
• Changes in the retina that may indicate macular degeneration (such as hard,
white deposits beneath the retina called drusen or broken blood vessels
called hemorrhages)
• Damaged blood vessels or bleeding in the back of the eye from diseases
such as high blood pressure or diabetes

• Cataracts

Use dimly illuminated room, ophthalmoscope set to low

brightness (to maintain a large pupil . Patient seated gazing at
far upper corner of room. Examiner standing view right eye with
right eye , left eye with left eye , try and keep keep both eyes
open, use finger on brow to stabilize view.

Initially start about 10 cm from the eye with the unit focused on
the pupil and observe the fundus reflex in the pupil. Look for
cataract and opacities.

Increase negative (move toward red numbers in the dioptric

adjustment wheel) values to bring fundus into focus.

If the pupil is too small:

Reduce illumination in the room and the scope and use a
smaller aperture on the scope.
PCD Notes, P Shaw O.D. 2006

Find the Optic disc ! Its horizontally level with patient primary
gaze observer moves 15 degrees temporal (away from midline).
It is that whitish tissue with the blood vessel clearly visible.
PCD Notes, P Shaw O.D. 2006

Visual field tests

Visual field tests may be done:

• To check for vision loss in any area of your visual field.

• To screen for eye diseases, such as macular degeneration and glaucoma, which
cause gaps in the visual field.
• As part of a neurologic exam following a stroke, head injury, or other condition that
causes reduced blood flow to the brain.

Visual field tests are used to check for gaps in your range of vision. They can help detect
eye diseases or nervous system problems that limit your ability to see objects clearly in
the entire visual field or in one part of it. Several tests are commonly done to evaluate a
person's visual field.

• The Confrontation test. Your health professional will sit or stand 2 ft(0.6 m) to 3
ft(1 m) in front of you. You cover one eye while fixing your gaze on the health
professional's nose. The health professional slowly moves a finger or hand from the
outer edge of your visual field toward the center and from the center toward the
edge through all areas of your visual field. You will focus your eye on your doctor's
nose and signal when you first see the health professional's finger or hand. The test
is then repeated for the other eye.

FYI: Extra info on Visual field tests:

• The Amsler grid test checks for macular degeneration, a disease that causes loss
of vision in the center of your visual field. The test uses a 4 in.(10 cm) square chart
with straight lines that form boxes. The grid has a black dot at the center. The chart
is held about 14 in.(36 cm) from your face. You will cover one eye while focusing
your other eye on the black dot. The test is then repeated on the other eye. Tell your
doctor if:
o You cannot see the black dot.
o You see a blank or dark spot (other than the center dot).
o The lines in the grid look wavy, blurred, or curved instead of straight. You
will be asked to point to the specific abnormal area of the grid.
• Perimetry testing uses a machine that flashes lights randomly at various points in
the visual field. You look inside a bowl-shaped instrument called a perimeter. While
you stare at the center, lights will flash, and you press a button each time you see a
flash. A computer records the location of each flash and whether you pressed the
button when the light flashed in that location. At the end of the test, a printout shows
any areas of your visual field where you did not see the flashes of light. In an
alternative manual perimetry test, your health professional moves a light target and
notes your visual field on paper.
• The Tangent screen test uses a black screen with concentric circles and lines
leading out from a center point (like a bull's-eye). Sitting 3 ft(1 m) to 6 ft(2 m) away
from the screen, you cover one eye while fixing your gaze on a target point marked
on the screen. Test objects of various sizes at the tip of a wand are then moved
inward from the outer edge of the screen toward the center. You will signal when
you can see the object, and that point is then marked on the screen. The points on
the screen where you see the objects are connected to provide an outline of your
visual field. The test is then repeated for the other eye. An alternative manual
tangent screen test uses a white object against a black background. If you wear
glasses, you will keep them on for this test.