Skill Performance Evaluation: Eye Examination

Directions: You will have 10 minutes to complete the skill*. All critical (C) steps and 80% of the noncritical steps
must be performed or verbalized. Special tests (S) will be performed if requested by examiner.
*These skills are performed bilaterally. Start: End:
Performed Verbalized
Washes hands and dons appropriate personal protective equipment. C
Introduces self to patient using first and last name. Y/N
Notes general appearance and vital signs. Y/N
General Vision
1. Visual acuity (OD, OS, then OU) with correction if needed Y/N
2. Visual field screening Y/N
3. Color vision S Y/N
Inspection
1. Assess lids: direction of eyelashes, discoloration, masses, lesions, edema Y/N Y/N
2. Assess each lacrimal apparatus: note swelling or tearing Y/N Y/N
3. Conjunctivae and sclerae: color, swelling, discharge, vascularity, nodules Y/N Y/N
4. Corneas and lenses: opacities Y/N Y/N
5. Irides: assess depth of the anterior chamber Y/N Y/N
6. Pupils: size/shape/symmetry/reaction to light (direct/consensual) and accommodation Y/N Y/N
7. Note corneal light reflections Y/N Y/N
8. Extraocular movements including convergence, looking for conjugate gaze, nystagmus,
Y/N Y/N
and lid lag
Special Tests
1. Cover/uncover test to test a deviated eye S Y/N
2. Eversion of upper lid and inspection of upper palpebral conjunctivae S Y/N
Ophthalmoscopic exam
1. Darken room and ask patient to focus on distant object Y/N Y/N
2. Use correct hand/eye for each of patient's eyes Y/N
3. Hold ophthalmoscope at a 15º angle from patient’s eye 15” away and note the red reflex Y/N Y/N
4. Move closer to the patient and focus the ophthalmoscope Y/N
5. Inspect the optic disc: color, clarity of outline, size of physiologic cup, symmetry
Y/N
between eyes, and any papilledema
6. Inspect the retina: distinguish arteries from veins; arteriovenous junctions; and note any
Y/N
lesions, masses, hemorrhages, or exudates
7. Inspect the fovea and macula for exudates, hemorrhages, cysts Y/N Y/N
Evaluation: #Y= #C =
min. = 27/33 min. = 1
Comments on quality of performance: Needs Remediation?

Y/N

Student: Evaluator: Date:

Developed by Albany Medical College, Center for Physician Assistant Studies | Bickley: Bates’ Guide to Physical Examination
and History Taking, Twelfth Edition. Copyright © 2017 Wolters Kluwer Health