Basic Physical Examination

Eye Examination

Vitaliy Sazonov, MD
NUSOM
 Learning Outcomes

1. To be able to inspect eye and surrounding

structures
2. Learn to measure visual acuity
3. Perform visual fields assessment by
confrontation
4. To be able to perform and interpret tests for
direct and consensual pupillary reactions
5. Perform testing of extra ocular muscles
6. Perform fundoscopic examination and identify
main structures of the retina
 Lecture Outline

1. Review of Eye Anatomy

2. General Inspection and Examination of the Eyes
3. Assessment of Visual Acuity
4. Visual Fields Confrontation Testing
5. Assessment of Pupillary Reactions (Direct/Consensual)
6. Extraocular Movements
7. Funduscopic Examination
 Anatomy of the Eye
• Important structures:
• Eyelid
• Sclera and Conjunctiva
• Cornea, Lens, Pupil, and Iris
• Retina and Retinal Vessels
• Macula/Fovea
• Optic Nerve, Disc, and Cup
• Vitreous Body
Anatomy of Eye and Adnexal structures
 General Inspection

• Eyebrows (quantity/distribution)
• Eyelids (position related to
eyeballs/width/color)
• Eyelashes (condition/direction)
• Lacrimal Apparatus (palpate)
 Inspection (cont.)

• Position and alignment of eyes

• Conjunctiva/Sclera (ask patient to look up {also
from side to side} and depress lower eyelid)
• Cornea/Lens
• Iris/Pupils (Size/Shape/Symmetry)
Eye lids
Eye drooping – ptosis
Common Causes: Neurogenic:
CN III palsy (usually complete
ptosis), Horner syndrome
(incomplete ptosis) symp. chain

Muscular cause: e.g.

Myasthenia Gravis

Mechanical cause:
Inflammation of soft tissues –
swelling

Inflammatory - acute
hordeolum or sty
 Conjunctiva and Sclera
• Pull lower eye lid and ask to look up
to examine conjunctiva and sclera

Conjunctivitis

Viral Conjunctivitis

Pale Conjunctiva- due

to severe anemia
 Sclera
Episcleritis- more superficial inflammation. Can
be due to trauma or infection, or systemic
disease (autoimmune). Common at younger
age

Scleritis – more deep, very painful. associated

with rheumatoid arthritis, connective tissue
disorders. Common in elderly
 Cornea and Lens
Check for opacities
Cataract – Opacity of lens
Causes: aging, metabolic
disorders, trauma or
hereditary

Causes of lens dislocation:

Trauma, Marfan’s syndrome, Homocystenuria
 Iris
• Shine light from temporal side and look for crescentic shadow
of the iris
• Can be a sign of glaucoma - increased intraocular pressure
 Assessing Visual Acuity
• Position patient 6 m (20ft) from well-lit Snellen Eye Chart.
• Patient should wear glasses if usually worn (not reading
glasses)
• Ask patient to cover one eye with a card.
• With uncovered eye, ask patient to read smallest line of print
possible.
• Record visual acuity designated at side of smallest line of print
from which patient can correctly read >50% of letters.
Snellen Chart
 Visual Acuity
• Visual acuity is expressed as two numbers
• First number represents distance of patient
from chart
• Second number represents distance person
with healthy vision can read same line
• 6/6 m (20/20 ft): normal vision
• 6/60m (20/200ft): legal blindness
 Assessing Visual Acuity (2)
• If patient cannot see any letters on chart,
reduce distance
• If unsuccessful, then attempt to have patient
count fingers, detect movement, and finally,
detect light
 Visual Acuity
• Patient seated at 6 m or 20 ft from the chart
• 20/20 = 100% visual acuity
• Myopia vs Presbyopia (short sighted vs farsighted)
• If Patient can not see any letters reduce the distance
• If still can not see use counting fingers, then,
movement, lastly light
 Assessing Visual Fields by
Confrontation
• Examiner stands (or sits opposite) ~1m in front of patient
facing patient.
• Patient need to remove their glasses
• Ask patient to look with both eyes open into your eyes.
• With both hands, make an imaginary circle between you and
patient.
• Ask patient to tell you when s/he sees your fingers wiggling.
• Or how many fingers they can see testing all 4 quadrants.

https://www.youtube.com/watch?v=2-9FVywV2j4
Example of Normal Visual Fields Chart
 Visual Field Testing by Kinetic Red Target Test

• If a deficit found, map out boundaries and

test each eye individually by covering the
other eye.
• Use red pin moving from periphery centrally
in all 4 quadrants

BY DR. VIJI K GEORGE VASAN EYE CARE

 Mapping Out Visual Field Defect

Normally, there is blind spot located 15

degrees temporally (laterally).

www.cns.nyu.edu
Common Neurological Lesions Causing
Defects of VF
 Pupillary Reactions to Light
• Ask the patient to look into distance, shine bright light
obliquely into each pupil.
• Direct reaction: pupillary constriction in same eye.
• Consensual reaction- Look for pupillary constriction in
opposite eye.
• If reaction is difficult to assess, darken lights in room.
Abnormal Reactions to Light
 Pupillary reflexes:
https://www.youtube.com/watch?v=E2XzBaOO
X8g
 Near Pupillary Reaction
• Check if reaction to light is abnormal
• Hold your finger ~10 cm from patient’s eye
• Ask patient to alternately look at it and into the
distance behind it
• Should see pupillary constriction with near effort
 Position and Alignment
• Shine a light into patient’s eyes and ask patient
to look at it.
• Light should be reflected from corneas slightly
nasal to center of pupils bilaterally.
• Observe for symmetrical light reflections in
corneas

Crossed eyes

Eyes do not line up

Crossed eyes or Walleyes
Can be due to muscular or neurological problem (e.g. palsies CN3,4, and 6)
Patient will have double vision

www.slideshare.net, twinpossible.com
 Extraocular Movements
Muscle Function Cranial Nerve Innervation
Inferior Oblique Moves Eye Upward and Inward CN III
Inferior Rectus Moves Eye Downward and Outward CN III
Lateral Rectus Lateral Deviation CN VI
Medial Rectus Medial Deviation CN III
Superior Oblique Moves Eye Downward and Inward CN IV
Superior Rectus Moves Eye Upward and Outward CN III
https://meded.ucsd.edu/clinicalmed/eyes.htm
 Assessment of Extraocular Muscles

• Ask patient to follow you extended finger with his/her

eyes without moving their head
• Make a wide H in the air with your finger
• Observe for abnormal movements, nystagmus, and lid
lag.
• Ask if patient has any double vision at any point
Draw Imaginary Letter H
 Extraocular muscles
• Inspect for reflections in the corneas
• Cover uncover test (checking for alignment)
• Look for Nystagmus
• Convergence
• Lid lag - hyperthyroidism
• CN7 palsy
Horizontal Nystagmus
Lid Lag
Left CN 6 Palsy (patient was asked to
look to his left)
Right CN 3 Palsy
 Using the Ophthalmoscope
• Use requires patience and practice!
• Most often used without dilation of patient’s eyes
• Dilation can significantly improve visualization of
posterior retinal structures
• Contraindications to mydriatic drops: head injury,
coma, suspected narrow-angle glaucoma
 The Fundoscopic Examination

• Perform without wearing glasses

• Darken room
• Turn on ophthalmoscope light and turn lens
disc until you see large round light beam
• Adjust light intensity on back of your hand
• Turn lens disc to the 0 diopter
• Adjust diopters according to your and
patient’s vision
 The Fundoscopic Examination (2)

• Hold the ophthalmoscope in your right hand

and use your right eye to examine the
patient’s right eye and vice versa
• Hold the ophthalmoscope against medial
aspect of your orbit
• Make sure that you can see through the
aperture
• Instruct patient to look up and over your
shoulder into distance
 The Fundoscopic Examination (3)

• Place yourself about 15 away from patient and at angle of 15

degrees lateral to the patient’s line of vision
• Shine the light beam on the patient’s pupil and look for red
reflex
• Place thumb of other hand across patient’s eyebrow
• Lower brightness to the lowest setting that allows you to
visualize retina
Orientation in the Fundus
 Using Ophthalmoscope
• Do not dilate
• Remove your and patient’s glasses (can keep
the contact lenses)
• Contraindications for mydriatic drops:
Head injury, coma, suspected narrow- angle
glaucoma
 Main Landmarks
• Enlarged cup may be result of Chronic open
angle glaucoma
 What to Look for?

• Locate the optic disc by following the blood vessels

• Inspect for:
 Clarity of the disc outline
 Color of the disc
 Size of central physiologic cup
 Cup to disc ratio (Normal ≤ ½)
 Retinal Examination Papilledema

• Inspect for venous pulsations

• Comparative symmetry
• Arteriovenous crossings
• Papilledema, sign of increased ICP
• Follow the vessels peripherally
• At the end examine fovea and macula
Normal Retina
ARMD
 Summary
• Always obtain a history prior to examination
• Eye exam may give very valuable information
about systemic disease
• Sometimes only focused exam is needed
• Do not use mydriatic eye drops. Do not dilate
• Practice using ophthalmoscope
Any Questions?
Thank You
 References:

1. Bickley, L. S., Szilagyi, P. G., & Bates, B. 11 the ed.

(2013). Bates' guide to physical examination and history
taking. Philadelphia: Lippincott Williams & Wilkins.
2. Susan Standring, Gray's Anatomy: THE ANATOMICAL BASIS OF
CLINICAL PRACTICE. 40th Edition, 2014