Ophthalmologic Evaluation
History
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Demographic data
Chief complaint
History of present illness
Past ocular history
Past systemic history
Family history
Demographic Data
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Name
Address
Date of birth
Gender
Race
Medical record number
Chief complaint
• Should be recorded in the patient’s own words
or in a nontechnical paraphrasing of the
patient’s words
History of Present Illness
• Time and manner of onset. Was it sudden or gradual?
• Severity. Has the problem improved, worsened, or remained the
same?
• Influences. What might have precipitated the condition, made it
better or worse, or made no difference?
• Constancy and temporal variations. Has the problem been
intermittent or seasonal, or does it worsen at a particular time of
day? If so, were there any influences that seemed to precipitate
exacerbations or remissions?
• Laterality. Is the problem unilateral or bilateral?
• Clarification. Clarify what the patient means by certain complaints.
• Documentation. Old records or old photographs can be of value in
documenting the presence or absence of particular problems in the
past.
Past Ocular History
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Use of eyeglasses or contact lenses
Use of ocular medications in the past
Ocular surgery (including laser surgery)
Ocular trauma
History of amblyopia (lazy eye) or of ocular
patching in childhood
Ocular Medications
• Current and prior ocular medications used for
the present illness
– Dosages
– Duration
– Frequency
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Over-the-counter medications
Home remedies
Herbal medicines
Dietary supplements
Past Systemic History
• Diabetes mellitus
• HTN
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Malignancy
Dermatologic
Cardiac
Renal
Hepatic
Pulmonary
GI
Autoimmune collagen vascular diseases (including arthritic)
• Surgeries
Allergies
• Allergic reactions to topical or systemic
medications
• Allergies to environmental agents resulting in:
– Atopic dermatitis
– Asthma
– Allergic rhinitis, conjunctivitis
– Urticaria
– Vernal conjunctivitis
Family History
• Ocular diseases
• Familial Systemic Diseases
– Atopy
– Thyroid disease
– HTN
– Diabetes mellitus
– Malignancies
Examination
• Visual acuity examination
• Examination of the external eye and ocular
adnexa
• Pupillary examination
• Posterior segment examination
Visual Acuity Notations and
Abbreviations
Abbreviation
Stands for
VA
Visual acuity
cc
With correction
sc
Without correction
PH
Pinhole
OD
Right eye
OS
Left eye
OU
Both eyes
J
Jaeger notation
Visual Acuity Notations and
Abbreviations
Abbreviation
Stands for
CF
Counting fingers
HM
Hand motion
LP c proj
Light perception with projection
LP s proj
Light perception without projection
NLP
No light perception
C
Central
S
Steady
M
Maintained
F/F
Fixes/follows
20/40-2
Missed 2 letters on 20/40 line
20/50+2
Read 2 letters on the line following the
20/50 line
Testing Distance Visual Acuity
1. Ask the patient to stand or sit 20 feet from the Snellen
chart.
2. Occlude the left eye.
3. Ask the patient to read down the chart as far as possible.
4. Note the corresponding acuity measurement at that line
of the chart. Record the visual acuity 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; for example 20/40-2. If acuity is worse than 20/20,
recheck with a pinhole.
5. Repeat steps 1-4 for the left eye, with the right eye
covered.
Low Vision Testing
• If a patient is unable to read the largest line of the visual acuity
testing chart at 20 ft, move the patient 5 ft closer to the chart (15
ft, 10 ft, 5 ft).
– Ex.: 5/200 (Patient can read the 20/200 line successfully while standing 5
ft in front of the chart)
• If the patient is unable to read the largest line at 5 ft, proceed to
measure ‘counting fingers’ vision. Ask how many fingers are held
up, and if an accurate response, record as CF and the distance
measured (4 ft, 3 ft, 2 ft, 1 ft).
• If CF cannot be seen, move your hand in front of the patient’s eye
and if movement is accurately seen, record a VA of HM.
• If hand movements are not perceived, shine a penlight into the eye
from various angles and record whether or not the patient has light
perception (LP), and from which direction it is perceived.
• If still no light perception, record the vision in that eye as NLP.
Testing Visual Acuity in
Preschoolers
• Tumbling E chart
– In this test, the only figure presented is an upper
case E.
– The E is presented in any one of four positions:
normal, backwards, upside down on its "back" and
turned with its back up.
– The child is asked to show which direction the E is
pointing by pointing with the hand.
Tumbling E chart
Testing Visual Acuity in Infants
• Fixes and follows (F & F)
or
• Central, steady, maintained (CSM)
Testing Visual Acuity in Infants
• If the baby can hold fixation on a target and
follow it around in space as the target moves,
this visual acuity is noted as "fix and follow".
• Make sure to check for fixation behavior with
each eye, as well as binocularly .
Testing Visual Acuity in Infants
• If each eye fixates centrally rather than
eccentrically, holds steady fixation on that
target rather than searching for it or
wandering, and continues to stay fixated on
that target even when occlusion is removed
from the fellow eye, the vision is noted
"CSM".
• Make sure to check for fixation behavior with
each eye, as well as binocularly.
Testing Visual Acuity in Infants
• If there is a fixation preference, then typically
the preferred eye has CSM for the visual
acuity and CSNM (central, steady, not
maintained) for the fellow eye.
• If there is nystagmus present, then the fixation
would likely be CNSM (central, not steady,
maintained) if the patient was fixating
centrally despite the nystagmus.
Testing Near Visual Acuity
1. Instruct the patient to hold the test card at a
distance specified on the card (14 inches).
2. Ask the patient to occlude the left eye.
3. Ask the patient to read the smallest print
that they can comfortably see.
4. Record the acuity value for each eye
separately, with and without correction.
5. Repeat the procedure with the right eye
occluded and the left eye viewing the chart.
Jaeger eye chart
Rosenbaum pocket vision screener
Amsler grid
• If you wear reading glasses, put them on
for this test.
• Hold the chart at a comfortable reading
distance.
• Cover one of your eyes.
• Look at the grid. Keep your eye focused on
the white dot at the center of the grid
throughout the test.
• Without moving your eye from the center
dot, notice the lines which make up the
grid. All of the lines should be straight, and
all of the squares should look the same.
There shouldn’t be any blank, dark, or
distorted areas on the grid. Use the same
procedure to test your other eye.
Amsler grid
Amsler grid
Eyelids
• Edema
• Redness
• Direction of the eyelashes
Eyelashes
• Matted eyelashes
Conjunctiva
• Hyperemia
Sclera
• Icteric
Cornea
• Opacities
Iris
• Color (brown in Asians)
Anterior Chamber
• With your light shining directly from the temporal side, look
for a crescentic shadow on the medial side of the iris.
• Since the iris is normally fairly flat and forms a relatively open
angle with the cornea, this lighting casts no shadow.
Pupils
• Size, shape, symmetry
• Pupillary reactions to light
– The direct reaction (pupillary constriction in the
same eye)
– The consensual reaction (pupillary constriction in
the opposite eye)
Extraocular Movements
• Ask the patient to follow your finger or pencil as you
sweep through the six cardinal directions of gaze.
• Making a wide H in the air, lead the patient’s gaze to
the patient’s extreme right
(2) to the right and upward
(3) down on the right
(4) without pausing in the middle, to the extreme left
(5) to the left and upward
(6) down on the left
Ophthalmoscope
Steps for Using the Ophthalmoscope
• Darken the room. Switch on the ophthalmoscope light and
turn the lens disc until you see the large round beam of white
light.
• Turn the lens disc to the 0 diopter (a diopter is a unit that
measures the power of a lens to converge or diverge light).
• Remember, hold the ophthalmoscope in your right hand to
examine the patient’s right eye; hold it in your left hand to
examine the patient’s left eye.
Steps for Using the Ophthalmoscope
• Hold the ophthalmoscope firmly braced against the medial
aspect of your bony orbit, with the handle tilted laterally at
about a 20° slant from the vertical. Check to make sure you
can see clearly through the aperture. Instruct the patient to
look slightly up and over your shoulder at a point directly
ahead on the wall.
• Place yourself about 15 inches away from the patient and at
an angle 15° lateral to the patient’s line of vision. Shine the
light beam on the pupil and look for the orange glow in the
pupil—the red reflex. Note any opacities interrupting the red
reflex.
Steps for Using the Ophthalmoscope
• Now, place the thumb of your other hand across the patient’s
eyebrow (this technique helps keep you steady but is not
essential). Keeping the light beam focused on the red reflex,
move in with the ophthalmoscope on the 15° angle toward
the pupil until you are very close to it, almost touching the
patient’s eyelashes.
Steps for Examining the Optic Disc and
Retina
• First, locate the optic disc. Look for the round
yellowish orange structure. If you do not see it
at first, follow a blood vessel centrally until
you do.
• Now, bring the optic disc into sharp focus by
adjusting the lens of your ophthalmoscope.
– If both you and the patient have no refractive
errors, the retina should be in focus at 0 diopters.
Posterior Pole
Optic Disc
• The sharpness or clarity of the disc outline
• The color of the disc
– yellowish orange to creamy pink
• The size of the central physiologic cup, if
present. It is usually yellowish white.
– Nomral cup-disc (CD) ratio: 0.3-0.5
Cup-to-disc ratio
• The ratio of the horizontal
diameter of the physiological cup
to that of the horizontal
diameter of the optic disc. It
should be less than 0.5. If it
exceeds that value, or if there is
a difference in ratio between the
two eyes, or if there is a
progressive enlargement of the
cup, glaucoma may be suspected
Cup-to-disc ratio
Normal optic nerve with small cup
Cup-to-disc ratio is 0.2
Moderately advanced cupping
Cup-to disc ratio is 0.7
Almost total cup with cup-to-disc ratio of 0.9
Retinal Blood Vessels
A/V Ratio
• The A/V ratio is the ratio of the arteries width
to the veins and a normal finding would be
2/3.
A/V ratio 2:3
A/V ratio 1:3