Clinical Medicine

HEENT – Physical Examination

Dr. Solis

EYES o Lateral and slightly inferior to the disc, there is a

• Examination of the eyes is primarily done in patients small depression in the retinal surface that marks
with: the point of CENTRAL VISION.
a. Eye complaints • Around it is a darkened circular area called the FOVEA.
b. Patients with comorbidities (systemic diseases o The roughly circular MACULA surrounds the Fovea,
like Diabetes and Hypertension) → high risk of but has no discernible margins.
developing eye problems • Superior Rectus → pulls eye UP
• Inferior Rectus → pulls eye DOWN
• Lateral Rectus → pulls eye LATERALLY
Eye (away from Nose)
Examination Extrinsic Eye • Medial Rectus → pulls eye MEDIALLY
Muscles (towards the Nose)
Motility • Superior Oblique → pulls eye LATERAL
Visual External Pupillary Optha and DOWN
and
Acuity Eye Exam Exam
Structure
Alignment • Inferior Oblique → pulls eye LATERAL
Lacrimal and UP
Apparatus General Rules
• At the beginning of every procedure:
1. Explain procedure
5 Components of a Basic or Screening Eye Examination 2. Ask permission
1. Visual Acuity (Central and Peripheral Vision) 3. Get consent
2. Assessment of the External Eye including the 4. Wash hands
Lacrimal Apparatus 5. Prepare equipment/supplies
3. Pupillary Examination → uses the penlight 6. Ensure patient’s comfort
4. Motility and Alignment Assessment → function of CN • At the end:
and EOM 1. Say thank you
5. Ophthalmoscopic Examination 2. Wash hands
I. BASIC CONCEPTS • Penlight
Anatomy and Physiology of the Eye Equipment • Ophthalmoscope
• Warm Hands
II. EYE EXAMINATION PROPER
Visual Acuity
1. Central Vision
a. Far Vision
b. Near Vision
2. Peripheral Vision
Assessment for Central Vision
• Far Vision using the SNELLEN CHART
• Near Vision using the JAEGAR CHART or ROSENBAUM
• The UPPER EYELID covers a portion of the IRIS but does POCKET VISION SCREENER or newspaper or magazine
not normally overlay the PUPIL. print
• The opening between the eyelids is called the Far Vision Test
PALPEBRAL FISSURE. • Assessed by using the
• The white SCLERA may look somewhat buff-colored at Snellen Chart
its periphery → Do not mistake this color for Jaundice, • Visual Acuity is reported
which is a deeper yellow 20/20
• The CONJUNCTIVA is a clear mucous membrane with
two easily visible components.
• The BULBAR CONJUNCTIVA covers most of the
anterior eyeball, adhering loosely to the underlying
tissue → it meets the CORNEA at the LIMBUS.
• The PALPEBRAL CONJUNCTIVA lines the eyelids.
• The LACRIMAL GLAND lies mostly within the bony
orbit, superior and lateral to the eyeball
• The EYEBALL is a spherical structure that focuses light
Pinhole Test
on the neurosensory elements within the RETINA.
• Test for detecting Refractive Errors
o The muscles of the Iris control pupillary size.
o Muscles of the CILIARY BODY control the thickness • If the visual acuity is less than the normal, use an
OCCLUDER WITH A PINHOLE to read the Snellen Chart.
of the lens, allowing the eye to focus on near or
distant objects. • The patient’s vision improves if he has refractive
• A clear liquid called AQUEOUS HUMOR fills the anterior errors and worsens with those with central problems
and posterior chambers of the eye. • Failure to read the largest letter in the testing chart
o Aqueous humor is produced by the CILIARY BODY, warrants low vision testing according to the
circulates from the Posterior Chamber through the decreasing visual function namely:
pupil into the Anterior Chamber, and drains out 1. Counting Finger (CF)
through the CANAL OF SCHLEMM → helps control 2. Hand Movement (HM)
the pressure inside the eye 3. Light Perception (LP)
• The posterior portion of the eye that is seen through Near Vision Test
the ophthalmoscope is often called the OPTIC FUNDUS • Makes use of a handheld card called the Jaeger Card.
• Structures here include the RETINA, CHOROID, FOVEA, • Helps to identify Presbyopia → impaired near vision
MACULA, OPTIC DISC, and RETINAL VESSELS. found in middle-aged and older people
o The Optic Nerve with its Retinal Vessels enters the • The card is held 14 inches from the patient’s eyes.
eyeball posteriorly, visible with an
ophthalmoscope at the OPTIC DISC

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 Clinical Medicine
HEENT – Physical Examination
Dr. Solis

• Left Optic Nerve Compression → Ipsilateral → Left Eye

Blindness
• Chiasmal Compression from Pituitary Tumor →
Bitemporal Hemianopsia
• Left CVA → Lesion on the Left Optic Tract →
Homonymous Left Hemianopsia
• A lesion that compresses the Optic Chiasma from one
side will result blindness of Nasal Part of the Visual
Field of the same side eye → Nasal Hemianopia
• The paragraph with the smallest print is J1, the next
paragraph is J2 and so on, progressively to the largest
print, J11.
• Persons with normal vision should be able to read J1
Assessment of Peripheral Vision
A. Visual Field Test
• Confrontation Test
• This test determines whether you have difficulty
seeing any areas of your Peripheral Vision → the areas
on the side of your visual field
Components of Visual Pathway

Neuroepithelial
Optic Nerve Optic Chiasm
Layer of Retina

Lateral
Optic Tract Optic Radiation
Geniculate Body

Occipital Cortex

• Each quadrant of the visual field is seen by the

opposite retina and visual pathway.
• The images in the Nasal Visual Field fall on the Quadrantanopia
Temporal Retina, and the Temporal Visual Field
images falls on the Nasal Retina, superior visual field

• A complete lesion of
one eye or completely
severing an Optic Nerve
will result in TOTAL
BLINDNESS of the
IPSILATERAL eye (and
the associated visual
field).

• Any lesion in the Visual Pathway may affect the

peripheral vision and result in Visual Field Defects

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 Clinical Medicine
HEENT – Physical Examination
Dr. Solis

• A lesion that interrupts 7. Eyelashes

the Optic Chiasma in its
middle part will result in
BITEMPORAL
HEMIANOPIA
(blindness in temporal
half of visual fields in
both side).
• Such narrowing of the
visual field is known as
“Tunnel Vision”
B. Confrontation Test
• Confrontation Testing of the visual
fields is a valuable screening
technique for detection of lesions in
the anterior and posterior visual
pathway
• Procedure:
1. Position yourself about an arm’s
length away from thse patient.
2. Close one eye and have the
patient cover the opposite eye
while staring at your open eye
3. Place your hands about 2 feet
Static Finger apart out of the patient’s view,
Wiggle Test roughly lateral to the patient’s
ears
4. While in this position, wiggle
your fingers and slowly bring
your moving fingers forward into
the patient’s center of view.
5. Ask the patient to tell you as soon
as he or she sees your finger
movement.
o Inspect eyelashes if it curves outward as
expected
o Note any matting, loss of misdirected lashes
and any infection occurring in the glands
around the eyelash hair follicles → Stye
8. Inspect Eyelids for symmetry, opening and
closing
9. Note the lid margin distance from the center of
the pupil
10. Note any marked eversion of the edge of the
lower eye lid (Ectropion) exposing the Palpebral
Conjunctiva
11. Note any marked inward turning of the lower
eyelid (Intropion)
12. Note for crusting, redness, swelling/edema of the
eyelids
o Red inflamed lid margins in Blepharitis
13. Instruct the patient to look up. Pull down the
lower lid of each eye to expose Inferior Sclera and
lower Palpebral Conjunctiva
o Using a PENLIGHT, inspect Sclera and lower
Palpebral Conjunctiva of lower eyeball for
color, swelling, and vascularity
o Describe the Sclera (white, dirty, icteric) and
Palpebral Conjunctiva for color (pinkish,
congested, pale) → Normal: White Sclera and
Pinkish Conjunctiva
14. Instruct the patient to look down. Pull up upper
eyelid of each eye to expose Superior Sclera and
Conjunctiva
15. Using a penlight, inspect Sclera and Conjunctiva
of the upper eyelid for color, vascularity, and
swelling
16. Inspect Cornea and Lens with oblique lighting
o Inspect the Cornea of each eye for opacities
o Note any opacities in the lens that may be
visible through the pupil
17. Iris
o Requires a penlight
o Inspect size, shape, markings, definition, and
color of the Iris with the light shining from the
temporal side

Protrusion and Recession of Eyeball

• As an example, when the patient’s left
eye repeatedly does not see your
fingers until they have crossed the
line of gaze, a Left Homonymous
Hemianopsia is present.
External Eye Examination
• Procedure: Lid Margin Distance
Proptosis
1. Stand in front of a seated patient
2. Inspect for position, symmetry, or alignment of
the eye
o Observe the position of the eyeball within the
confines of the bony orbit (socket)
o Look for:
a. Protrusion
b. Recession of one or both globes Ectropion Intropion
3. Stand behind the patient and ask him to tilt his
head backward to detect protrusion of eyeball or
PROPTOSIS
4. View the patient’s eye from behind and observe
the distance from the brow
5. Inspect any lid movements such as blinking every
second, lid twitching, or jiggling of the eyes
Blepharitis Inspection of Lower Lid
(Nystagmus)
6. Eyebrows
o Inspect eyebrows for texture, note for
quantity, distribution, or Alopecia, and
scaliness of the underlying skin or presence
of Seborrhea Inspection of Upper Lid

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 Clinical Medicine
HEENT – Physical Examination
Dr. Solis

Pupillary Examination • In assessing the Extraocular Muscles, look for:

Pupillary Reaction 1. The normal conjugate movement of the eyes in
A. Light Reaction each direction or any deviation from normal
B. Near Reaction 2. Nystagmus → a fine rhythmic oscillation of the
Pupillary Light Reaction eyes a few beats of Nystagmus on extreme lateral
• Procedure gaze are normal
o In a dim light, inspect the size, shape, and 3. Lid Lag as the eyes move from up to down
symmetry of both pupils • Procedure:
o Measure the pupils with a card showing black 1. Position yourself 2 feet (24 in) in front of the
circles of varying sizes and test the light reaction patient
o Note if the pupils are large (>5 mm) or small (<3 2. Instruct patient to keep his/her head stationary
mm) or unequal 3. Instruct the patient to follow your index finger or
pen with his eyes only
4. The path may trace out the letter “H”
5. Ask the patient to follow your finger or pencil in 6
cardinal directions of gaze
6. Move your index finger to either the extreme right
• A difference in pupillary diameter of or left
0.4mm or greater without a known 7. Move fingers slowly to extreme position of each
pathologic cause of the 6 cardinal positions of gaze returning to
• Visible in 35% of health people and the central starting point before pointing toward
Simple rarely exceeds 1mm the next field
Anisocoria • Simple Anisocoria is considered 8. When the person looks toward the most distal
benign if it is equal in dim and bright point in the lateral and vertical fields, carefully
light, and there is brisk pupillary note eyeball movements for normal conjugate
constriction to light (the Light movements and Nystagmus
Reaction)
• Procedure:
1. From the lateral side of each eye,
flash the penlight swiftly into the
Direct Light
eye being examined
Reflex
2. Observe for immediate
constriction of the pupil in the
same eye
• Procedure:
1. Ask the patient to rest the radial
side of his L or R hand in between
Indirect the eyes
H Maneuver
(Consensual) 2. From the lateral side, flash the
Light Reflex penlight into on eye and observe
for pupillary constriction of the
opposite eye
3. Observe both pupils
Near Reaction
• Accommodation and Convergence
o The Oculomotor Nerve (CN III) mediates the
pupillary constriction as the patient focuses on a
near object → NEAR REACTION
o On the other hand, Pupillary Dilatation can be
appreciated when the patient looks from near to
far distance 9. If on downward gaze, the upper lid remains
retracted (lags behind) and unable to follow the
iris in its downward movement, exposing the rim
of Sclera above the Limbus → patient has Lid Lag
(Von Graefe’s Sign)
Convergence Test

• Procedure:
1. Hold your index finger approximately 2 feet from
the patient’s eyes
2. Ask the patient to focus on the index finger as you
move it towards the patient’s nose • Procedure:
3. Note the pupillary constriction as the finger 1. Hold the target in the midline and at the eye level
moves closer (Accommodation) and crossing of about 50 cm (20 inch) from the face gradually
the eyes (Convergence) moving the target toward the bridge of the nose
Motility and Alignment 2. Convergence is normally maintained until 2-3
Extraocular Muscle Test inches (50 mm) from the bridge of the nose
• This test examines the muscles that control eye
movement
• The movement of each eye is controlled by the
coordinated action of 6 muscles: 4 Rectus and 2
Oblique Muscles

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 Clinical Medicine
HEENT – Physical Examination
Dr. Solis
III. SPECIAL TECHNIQUES
• Includes:
A. Nasolacrimal Duct Obstruction
B. Inspection of the Upper Palpebral Conjunctiva
C. Assessment for Protruding Eyes
A. Nasolacrimal Obstruction Test
• This test helps identify
the cause of excessive
tearing
• Procedure:
1. Ask the patient to look up
2. Press on the lower lid close to the Medial
Canthus, just inside the rim of the Bony Orbit →
this compresses the Lacrimal Sac
3. Look for fluid regurgitated out of the Puncta into
the eye
4. Avoid this test if the area is inflamed and tender
B. Assessment for Protruding Eyes
• Eye Protrusion → Proptosis or Exophthalmos
• For eyes with Exophthalmos, or unusual forward
protrusion, stand behind the seated patient and
inspect from above
• Draw the upper lids gently upward, then compare the
protrusion of the eyes and the relationship of the
corneas to the lower lids
• When protrusion exceeds normal, further evaluation
by Ultrasound or Computerized Tomography Scan
often follows
• For objective measurement, Ophthalmologists use an
Exophthalmometer
o This instrument measure the distance between
the lateral angle of the Orbit and an imaginary line
across the most anterior part of the Cornea
• The upper limits of normal are 20-22 mm
Everting the
Upper Eyelid
• Hold the ophthalmoscope in your right hand and use
• This keeps you from bumping the patient’s nose and
IV. OPHTHALMOSCOPIC EXAMINATION
• Procedure:
• Guidelines:
1. Darken the room or turn the patient away from
the direct light source
2. Stand in front of the patient sitting on the
examining table
3. Instruct the patient to look at a distant point
• The physiologic cup, if present, is normally yellowish
keeping his/her eyes focused on that distant
point throughout the Ophthalmoscopic Exam and
• Its horizontal diameter is usually less than half the
to try not to move his eyes
4. Initially, choose to set the aperture wheel to the
small spot that is generally used for General
Undilated Fundus Examination
5. Set Ophthalmoscopic Lens at 0
6. Some clinicians like to use the LARGE ROUND
BEAM for large pupils, and the SMALL ROUND
BEAM for small pupils.
o The other beams are rarely helpful.
o The slit-like beam is sometimes used to
assess elevations or concavities in the retina,
the green (or red-free) beam to detect small
red lesions, and the grid to make
measurements.
7. Either wear or remove own corrective glasses but
the patient’s should be taken off.
o However, if the patient is wearing a contact
lens, one may leave the contacts in place
8. From an angle of about 15-20 degrees lateral to
the patient’s line of vision, shine the O towards
the pupil of the right eye and look through the
Viewing Hole
9. Try to keep both eyes open when performing the
exam
10. Note for ORANGE GLOW in pupil
o I.e., the RED REFLEX from Retina
11. Inspecting the Anterior Chambers, Lens, and
Vitreous Humor
o Continue to look through the viewing window
and focus on the Red Reflex
o If not, slowly move closer towards the
patient’s forehead and these structures
become clear
o Note for any lens opacities (Cataracts) that
may interfere with Red Reflex Visualization
o If present, change the Aperture Wheel to a
larger spot to overcome the obstruction and
visualize the structures behind it better
12. Diopter Disc
o Turn the Diopter Discs COUNTERCLOCKWISE
for Convex (Plus) Lenses which are printed in
black: 0, +1, +2, +3, +4, +5, +6, +8, +10, +12, +16,
+20
o Turn the Diopter Discs CLOCKWISE for
Concave (Minus) Lenses which are printed in
red: 0, -2, -3, -4, -5, -6, -8, -10, -12, -14, -16, -
20, -25, -35D, until the sharpest focus is
achieved
your right eye to examine the patient’s right eye; hold
it in your left hand and use your left eye to examine
the patient’s left eye.
gives you more mobility and closer range for
visualizing the fundus.
Visualization of the Optic Disc
1. Focus further on the retinal structures such as a
vessel or the Optic Disc, further rotating and
adjusting the lens until the sharpest focus is
achieved
2. Find a blood vessel and follow it in the direction
in which the vessel thickens leading you visually
to the disc
3. Describe the shape, color, and border of the disc
4. Compare the color of the physiologic cup to that
of the disc. Take note of the Cup:Disc Ratio
• Note for its clarity, disc margin
should be sharp and well-defined
• Round or oval vertically
Optic Disc • Color is Yellowish-Orange to Creamy
Pink Oval
• Measures about 1.5mm in diameter
and 3 Diopters of Elevation = 3 mm
white.
horizontal diameter of the disc
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 Clinical Medicine
HEENT – Physical Examination
Dr. Solis

Inspection of the Retina

1. Inspect the Retinal
Vessel

Normal Retinal Artery

2. Follow the vessels
peripherally in each of
four directions

Arteries Veins
Color Light Red Dark Red
Size Smaller (2/3 to Larger
Diameter of Vein)
Light Reflex Bright Absent
• Normal AV Ratio = 2:3 or
4:5
• Arteriovenous (A-V)
Crossing

Renal Arteries in
Hypertension

3. Inspect the Macula

o The is an AVASCULAR AREA, somewhat larger than
the disc with no distinct margin
o To locate the Macula, focus on the disc, then move
the light temporally about 2 discs diameter
o To bring it into your vision, ask the patient to look
directly at the light
o In the center of the Macula, the FOVEA appears as
a smaller darker read area in the Retina

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