THE EIGHT- PART EYE
EXAMINATION
Visual Acuity
External Eye Examination
Ocular Motility
Pupillary Examination
Visual Field Examination
Slit Lamp
Biomiscroscopy
Tonometry
Ophthalmoscopy
I. Visual Acuity
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 wall chart)
2. Occlude the poorer eye or the eye in complaint. 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.
3. 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.
4. Note the corresponding acuity measurement shown on that line of the chart. Record the
acuity value for each eye 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) If acuity is less than 20/20, recheck with a 2.4 mm
pinhole. .
5. Repeat steps 1 through 4 for the left eye, with the right eye covered. 6.
Record as:
CC (With correction)
SC (Without correction)
VAOD
VAOD
OS
OS
Testing Pinhole Visual Acuity
( for medical students, pre-clinical level )
1. Position the patient and occlude the eye not being tested, as done for the distance acuity
test.
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. Ask the patient to begin to 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.
PHOD
OS
Testing Near Acuity
( for medica1 students, pre-clinical level )
1. 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).
2. Ask the patient to occlude the poorer eye or the eye in complaint.
3. Ask the patient to say each letter or read each word on the line of smallest characters
that are legible on the card .
4. Record the acuity value for each eye separately in the patient's chart.
5. Repeat the procedure with the right eye occluded and the left eye viewing the test chart
6. Repeat the procedure with both eyes viewing the test card
7. Record the binocular acuity achieved.
JOD
OS
II. External Eye Examination
The external ocular examination consists of a three-part step-wise sequence
the focuses the examiner's senses on the patient. They include:
1. inspection
2. palpation
3. ausculatation
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
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.
Corneal Sensation
( for clinical clerks)
1. Without touching the eyelashes or stimulating the visual startle reflex, touch the cornea with
a clean cotton wisp, facial tissue wick, or puff of air from a small syringe. A brief touch
should produce a reflex blink with a faint subjective sensation.
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 eyelids of the opposite eye and fixate on a straightahead target.
An optical bruit can signify the presence of a carotid-cavemous fistula or an arteriovenous
malformation. On the other hand, a faint rumbling noise heard over the globe is considered normal
Supplemental Text for the External Eye Examination
The external eye examination provides an overview of relatively gross abnormalities of the adnexae
and some of the more anterior ocular structures.
They may be listed in an anatomically logical order:
1. Eyelids and eyelashes
2'. Conjunctiva
3.' Episclera and sclera
4. Cornea and Anterior chamber
Eyelids and Eyelashes
Tumors (including non-neoplastic mass lesions) and blepharitis (inflammation of the
eyelid) are the most common findings of the eyelids.
A hordeolum is an acute abscess of a sebaceous gland (Zeis or meibomian) gland of
the eyelid. 2 variations occur:
1. External hordeolum, or stye, is an acute inflammation of the Zeis gland
2. Internal hordeolum is an acute inflammation of the meibomian gland
A chalazion is a subacute or chronic granuloma surrounding lipid that has been
extended into the tissues from a blocked sebaceous gland of the eyelid
Folliculitis is an acute abscess of, a surrounding eyelash follicle, rather than a sebaceous gland.
Folliculitis is nearly always caused by acute staphyloccal infection and is
not a precursor to chalazion.
,
Blepharitis (inflammation if the eyelids) manifests in a variety of forms. Depending on the cause.
Anterior or marginal blepharitis may be bacterial in origin or seborrheic, or caused by mites, lice or
dermatitis.
a) Staphylococcal blepharitis
-Characterized by collarettes - thin horny-colored flakes surrounding and lying
among eyelashes
b) Seborrheic blepharitis
-Dandruff-like flakes (scurf) are randomly distributed on and among the
'
eyelashes
c) Demodectic blepharitis
-Caused by infection of the eyelashes with a mite, Demodex folliculorum
-Typified by the presence of waxy-appearing, cylindrical cuffs or "sleeves': around the bases
of the eyelashes
d) Posterior blepharitis/meibomianitis
-excessive secretion of the meibomian glands with abnormally thick and perhaps otherwise
biochemically abnormal secretions
e) Angular blepharitis
-affects mainly the medial or lateral canthal areas of the eyelid, which show
eczematoid or ulcerative changes of the skin
Other signs associated with by long-standing staphylococcal blepharitis:
a) madarosis-loss of eyelashes
b) poliosis-whitening of eyelashes
c) trichiasis-misdirection of eyelashes, often as to cause them to rub the eye
III. Ocular Motility
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.
The two primary types of vergences routinely evaluated are convergence. (the movement
of both eyes nasally), and divergence, (the movement of both eyes temporally. )
Assessing the Ocular Movements
( for medical students, pre-clinical level)
1.Sit facing the patient. Hold your finger or a small fixation target at eye level 10 to 14 inches in
front of the patient looking in a primary position (straight ahead).
2. Ask the patient to follow the target as you move it into the six cardinal fields and up and down
along the midline. Elevate the upper lid with a finger on your free hand to observe down gaze.
3. Note whether the amplitude of eye movements is normal or abnormal in both eyes. Rate the
amplitude for both fields by considering normal amplitude to be 100% and rate lesser
amplitudes accordingly. .
4. Note any nystagmus that may be present and record the nystagmus according to its presence,
direction and amplitude in any field of gaze where applicable.
IV. Pupillary Examinations
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 maintain fixation on a distance
target, such as a large letter on the Snellen acuity chart.
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.4
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 clinical clerks)
1. Under dim room illumination with the patient fixating a distance target, illuminate
the patient's right eye directly with a bright handheld light, in a manner identical
to that used when testing the light reflex. Note pupillary constriction in both eyes.
2. Move the light beam immediately and swiftly over the bridge of the patient's nose
to the left eye, noting the pupillary response in that eye. Normally, the pupil will
either constrict slightly or remain at its previous size.
If Instead, the pupil dilates when the light illuminates it (i.e., the direct light reflex
is weaker than the consensual reflex) a relative afferent pupillary defect is present,
which usually indicates a disorder of the optic nerve or severe, retinal pathology.
3. Quickly swing the light back to the right eye to evaluate the response. A normal response is again a
mild constriction or no change in size at all. Net pupillary constriction or dilation is an abnormal
response.
4. Repeat steps 1-3 rhythmically, spending equal intervals illuminating each pupil, until it is clear
whether pupillary responses are normal or whether one pupil consistently dilates.
5. Record a relative afferent pupillary defect (RAPD) as 1+ to 4+. 1+ indicating a
mild defect and 4+ indicating an amaurotic pupil.
V. Visual Field Examination
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. Close your eye that is
directly opposite the patient's occluded eye.
3. Ask the patient to fixate on your nose or on your open eye.
Check for Scotoma
4. Finger counting. Hold your hands stationary midway between yourself and the patient in
opposite quadrants about 30° from central fixation. Quickly extend then retract a finger or fingers
on one hand in one quadrant of the monocular field, asking the patient to state the number. To
avoid confusion, limit the number of fingers shown to 1, 2, and 5, and hold the fingers side by side
in the frontal plane. Repeat in all four quadrants, testing at least two times per quadrant.
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 transilluminator
or penlight toward the pupil while keeping the patient's other eye completely
shielded.
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.
5. Simultaneous finger counting. Present fingers simultaneously in opposite quadrants, asking the
patient to state the total number, using the following combinations: 1 and 1, 1 and 2, and 2 and 2.
This test can reveal a more subtle field defect than finger counting in each quadrant separately.
6. Simultaneous comparison. Hold both palms toward the patient, close to the line of sight, in
opposite superior, then inferior quadrants. Ask the patient to state whether one hand appears darker
or less distinct. This test is very subjective and relies on equal illumination but can reveal a subtle
defect in a hemifield.
Diagram the Confrontation Field
7. If an abnormality is detected, sketch a 3600 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"
T
N
T
Performing the Amsler Grid Test
(for resident)
Test Set-up
1. With the patient. wearing appropriate reading spectacles or trial lenses for nearcorrection, 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. Ask the patient to fixate steadily at the central spot of the grid.
3. 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
4. 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.
Conjunctiva
The conjunctiva is best evaluated in a stepwise anatomically logical fashion beginning with the
palpebral conjunctiva, then proceeding to the limbal and bulbar conjunctiva
Coniunctival injection or hyperemia
-Increased blood flow with associated dilation of blood vessels in tile conjunctiva
produces more or less diffuse redness that is usually most prominent peripherally, tending to fade as the
limbus is approached. This is entirely nonspecific and can occur with practically any ocular
inflammation, dryness, environmental irritants and the like.
Ciliarv (limbal flush),
-The anterior ciliary vessels form a perilimbal plexus within the conjunctiva and episclera. When
hyperemic, these vessels can be seen to extend outward from the limbus for 1-2mm in a radial pattern.
This is seen as a red to violaceous, circumcorneal ring of dilated blood vessels. It indicates corneal,
episcleral, scleral or intraocular inflammation.
Secretions and Discharge
.
a) watery discharge - actually a secretion rather than discharge; it represents reflex tear flow
from the lacrimal glands. The term tearing is used when excess tears merely accumulate
within the conjunctival sac. The term epiphora is used if tears spill over the eyelid margin
onto the face. Tearing and epiphora may be caused by any irritation of the ocular surface such
as inflammation or foreign bodies.
'
b) mucus-a secretion of the goblet cells and is seen as a neany clear, sticky material on the
ocular surface. It is a non-specific finding brought about by an irritation of the conjunctival
surface.
c) mucopurulent discharge -consists of neutrophils admixed with mucus and signifies a
relatively mild
bacterial or allergic conjunctivitis
d) mucopus'-neutrophils give the mucus a whitish appearance
-tends to accumulate during sleep and is likely to be more noticeable early in the
morning
e) purulent discharge - consists entirely or mainly of neutrophils and is usually copious
- most often occurs with gonococcal or meningococcal conjunctivitis,
bacterial or fungal
corneal ulcers and abscess
Chemosis
Edema of or beneath the conjunctiva It appears as a thickening or ballooning of the
tissue. This is usually caused by allergy but may be seen in episcleritis, scleritis,
uveitis, endopthalmitis and, orbital cellulitis.
Episclera and Sclera Episcleritis
Immunologically mediated inflammation of the tissue that lies between the deep conjunctival
stroma and the sclera. It is benign, short-lived, and not associated with tenderness, ciliary
pain, or flare and cell. Usually caused by allergy to foods or airborne allergens.
Scleritis
Immunologically mediated inflammation of the sclera itself. Deep hyperemia, tenderness and
ciliary pain is present. It has a more prolonged cause and can cause damage and
complications. There is a detectable systemic illness in half of afflicted patients.
Pigmentations
a) Congenital melanosis oculi - an anomaly which produces deep slate-gray patches
of scleral and episcleral pigments.
b) Blue nevus - located deep in the conjunctiva or in the epiclera with a dark blue
color.
Cornea and Anterior Chamber
The cornea is best examined with a slit lamp biomicroscope but certain gross
abnormalities may be seen using a penlight.
.
-
a) Pannus superficial corneal vascularization with some fibrosis. They occur as a
response to superficial necrosis or hypoxia
b) Band Keratopathy - calcium deposits noted in the interpalpebral zone of exposure, they
usually extend across the entire cornea
c) Corneal scars - grey-white and permanent but become less opaque with time. They are
graded according to severity:
i. nebula - faint haze seen only with magnification; does not interfere with vision
ii. macular scar - seen without magnification and appears grey, has variable effects
on vision
.
iii. leukoma - white, seen without magnification and interferes with vision if located
in the visual axis
d) corneal edema - corneal haze which could be attributed to dysfunction in either the
corneal epithelium, stroma or endothelium
The anterior chamber is the area between the iris and the corneal epithelium. It is filled
with aqueous humor. Just like the cornea, the AC is best examined with a
biomicroscope. However, certain pathologies may be seen grossly.
a) hyphema - blood in the anterior chamber, usually from trauma if the amount of
blood is sufficient, it settles inferiorly forming a flat-topped layer of blood.
b) Hypopyon - purulent exudates (pus) in the anterior chamber, usually in
conjunction with corneal or intraocular infections.
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.
Performing Schiotz Indentation Tonometry:
( for Residents)
.
1. Check for proper calibration of the instrument by positioning the tonometer foot plate with
the weighted plunger in place on the smooth convex surface ( testing plate) provided
within the instrument case. If calibration does not register zero on full depression, a
factory recalibration is necessary. .
2. Instill a drop of topical anesthetic into each of the patient's eyes.
3. Place a 5.5 g weight on the Schiotz tonometer.
4. Position the patient lying on his or her back or tilted back in the
examination chair and fixating on the ceiling.
5. Using your nondominant hand, gently spread the eyelids of the right eye
open with the fingertips, being careful not to apply any pressure on the
globe or orbit.
6. Grasp the handles of the tonometer with the thumbs and index finger of
your dominant hand and align the scale so it faces you.
7. Maintaining the instrument in a vertical orientation, gently lower it onto the patient's
cornea until the foot plate is resting on the cornea. You may balance your thumb on the
bridge of the patient's nose and your other
fingers on the patient's forehead to steady your hand.
8. Read the scale and lift the instrument straight up and off the patient's eye.
9. Using the calibration table that comes with the instrument, determine the
intraocular pressure in mm Hg and record your results in the patient's chart.
Note: the lower the scale reading, the higher the IOP on the calibration table.
10. If the scale reading is less than 4 ( indicating .an elevated intraocular pressure), add the
7.5 g weight and repeat the measurement. At very high pressures, the Schiotz tonometer is
more accurate with a larger
weight in position.
.
11. Repeat steps 5-10 for the left eye.
Performing Goldmann Applanation Tonometry
(for Residents)
1. Insert a clean tonometer tip in the biprism holder. The 180 degree marking on the
tonometer tip should be aligned with the white line on the biprism holder.
2. Instill a topical anesthetic drop and fluorescein dye into each of the
patient's eyes.
.
3. Seat the patient at the slit-lamp with the patient's forehead firmly against
the headrest and chin comfortably with the chin rest. The patient's eye
should be aligned with the black band on the headrest column. Instruct the
patient to look straight ahead and to open the eyelids wide. The
examiner should be seated facing the patient, behind the slit-lamp
oculars.
4. Position the cobalt filter in front of the slit-lamp illumination device. The
cobalt-blue light causes the fluorescein dye on the patient's eye to
fluoresce a bright yellow-green.
5. Set the magnification of the slit lamp at low power, with the light beam at
high intensity and shining on the tonometer tip at a wide angle ( about 60
degrees) .
6. Looking from the side, use the slit-lamp control handle to align the tonometer tip with the
patient's right cornea. Adjust the numbers on the tonometer force adjustment knob to read
anywhere between 1 and 2 ( 10 and 20 mm Hg ).
7. Instruct the patient to focus on your right ear, blink once (to spread the
fluorescein dye), and then try to avoid blinking.
8. Using the slit-lamp control handle, gently move the biprism forward until it just touches
the cornea. Looking through the slit-lamp oculars, confirm that the biprism has just
touched the cornea; the spot of fluorescein will break into two semicircles, one above and
one below a horizontal line. Raise and lower the slit lamp biomicroscope with the control
handle until the semicircles are equal in size. The semicircles can be viewed monocularly
through only one of the slit-lamp oculars; in most slit-lamps the semicircles are viewed
through the left ocular.
9. Slowly and gently turn the force adjustment knob in the direction required to move the
semicircles until their inner edges just touch and do not overlap.
10. With the slit-lamp control handle, pull the tonometer biprism away from the patient's eye.
Note the reading on the numbered dial of the force adjustment knob. Multiply the number
by 10 to obtain the intraocular pressure in mm Hg, and record the pressure in the patient's
chart.
11. Repeat the procedure for the left eye.
VII. Tonometry
Tonometry is the measurement of intraocular pressure ( lOP). It is performed as part of a thorough ocular
examination to help detect ocular hypertension and glaucoma and to detect ocular hypotony ( low lOP) in
conditions such as iritis and reinal detachment. .
By convention, lOP is measured in millimeters of mercury (mm Hg ). Although there is no strict cutoff
between normal and abnormal intraocular pressures, most people have lOPs between 10 and 21 mm Hg.
Performing Digital Tonometrv
( 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 lOP 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 lOP 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
on the superior aspect of the patient's right 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. A normotensive eye roughly approximates the tone of the tip of the nose, an eye
with elevated pressure approximates the tone of the glabella and a hypotensive eye is
similar in tone to that of the lips.
4. Repeat the same procedure on the other eye.
VIII. Ophthalmoscopy/Funduscopy
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 Ophthalmoscopv
( 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. Focus the ophthalmoscope by twirling the dial for the Rekoss disc. 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 at 2 feet and 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. The patient is instructed to stare into the distance.
4. Dial the ophthalmoscope's focusing lens to clarify the fundus
image. Optimal viewing occurs 2-3 cm from the patient's eye.
5. As the patient stares at the distance target, the ophthalmoscope is
angled 15 degrees temporal to fixation so that the patient's optic
disc is at or near the first visible field.
6. Find the optic disc by following a retinal blood vessel. The arrows formed by vascular
bifurcations point to the optic disc. Depending on thh patient's refraction, the entire disc or
only a portion of it will be visible in anyone view. Assess the cup:disc ratio.
7. From the optic disc, follow the optic disc outward to examine the superonasal, inferonasal,
inferotemporal and superotemporal areas around the posterior pole. Note the vascular color,
caliber, bifurcations, crossings and the surrounding background. Take
note of hemorrhages and exudates if present.
8. Examine the macular area for any irregularities.
9. Repeat steps 1-8 on the other eye.