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Clinical skills we will teach

1. Snellen eye chart use

2. Pinhole test
3. Near sight test
4. Pupillary response - swinging flashlight test (includes Pupil Light reflex and the consensual
light reflex)
5. Confrontational visual field test
6. Ocular movement testing
7. Accommodation test
8. Ophthalmoscope use
9. Ishihara Colour testing chart
10. Amsler chart testing.
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1. Snellen eye chart

Indications

• To provide a baseline recording of visual acuity (VA)

• To aid examination and diagnosis of eye disease or refractive error
• For medico-legal reasons

Equipment

• Multi-letter Snellen chart

• E or C Snellen chart or a chart with illustrations for patients who cannot read or speak
• Plain occluder (not essential)
• Pinhole occluder
• Torch or flashlight
• Patient's documentation

A multi-letter Snellen chart (left) and a chart with illustrations.

Note: At the bottom of each Snellen chart is the distance it is to be read from. Some will be six meters
others 3 meters. You need to measure out this distance otherwise the arcs of measurements
and standards will be incorrect.
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Procedure

• Ensure good natural light or illumination on the chart.

• Explain the procedure to the patient.
• Wash and dry the occluder and pinhole. If no plain occluder is available, ask the patient to wash
his/her hands as they will use a hand to cover one eye at a time.
• Test each eye separately – the ‘bad’ eye first.
• Position the patient, sitting or standing, at 6 metres from the chart.
• Ask the patient to wear any current distance spectacles, to cover one eye with his/her hand (or
with a plain occluder), and to start reading from the top of the chart.
• The smallest line he/she can read (the VA) will be expressed as a fraction, e.g. 6/18 or 6/24
(usually written on the chart). The upper number refers to the distance the chart is from the
patient (6 metres) and the lower number is the distance in metres at which a person with no
impairment should be able to see the chart.
• In the patient's documentation, record the VA for each eye, stating whether it is with or without
correction (spectacles), for example:

• If the patient cannot read the largest (top) letter at 6 metres, move him/her closer, one metre at
a time, until the top letter can be seen – the VA will then be recorded as 5/60 or 4/60, etc.
• If the top letter cannot be read at 1 metre (1/60), hold up your fingers at varying distances of
less than 1 metre and check whether the patient can count them. This is recorded as counting
fingers (CF). Record as: VA = CF
• If the patient cannot count fingers, wave your hand and check if he/she can see this. This is
recorded as hand movements (HM). Record as: VA = HM
• If the patient cannot see hand movements, shine a flashlight toward his/her eye from four
directions of a quadrant.
• If 6/6 (normal vision) is not achieved, test one eye at a time with a pinhole occluder (plus any
current spectacles) and repeat the above procedure at 6 metres only. The use of the pinhole
enables assessment of central vision.

• If the vision improves, it indicates the visual impairment is due to a refractive error, which is
correctable with spectacles or a new prescription.
• Repeat the whole procedure for the second eye.
• Summarise the VA of both eyes in the documentation, for example:

If using the E or C chart:

• Point to each letter on each line and ask the patient to point in the direction toward which the
open end of the letter is facing.
• Follow the same procedure and recording methods as above.

Above is from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2040251/

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A note on recording your findings.

If there is one error on one line for example 6/12 on the right eye you would write
Right 6/12 -1
If there were two errors on that line with the right eye you would write
Right 6/12-2

U tube.

The two u-tube links are adequate provided you understand that they are using imperial measurements
rather than metric which Australia uses. The first U-tube mentions this. So, their 20:20 (feet) is
equivalent to our 6:6 (meters).

PLEASE QUOTE ALL MEASUREMENTS IN METERS- THIS IS WHAT OUR STANDARD AND CHARTS ARE SET.

http://www.youtube.com/watch?v=zDOdAfRurGs Boring presenter but some good points

https://www.youtube.com/watch?v=kMwy06mAV5U Does well but in imperial and misses some

explanation.

2. Pin hole test

A quick and easy way to determine whether refraction is the culprit, short of testing different lenses, is
with the pinhole test. Punch a small hole in a paper card, and have your patient reread the eyechart
while looking through this pinhole. This can improve vision by several dioptres. It works because the
paper blocks most of the misaligned rays that cause visual blur and allows the central rays to focus on
the retina. If your patient shows no improvement with pin holing, start thinking about other visual
impediments like cataracts or other media opacities.

3. Near vison test

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This is like the distance vision test above, but it is held only 14 inches (35 centimetres) away. If you wear
glasses for reading, wear them for the test.

Hold the near vision test card about 14 inches (35 centimetres) from your eyes. Do not bring the card
any closer. Read the chart using each eye separately as described above. Record the size of the smallest
line you were able to accurately read.

Example

If you can read the second lowest line with right N5,

If you can read the third line from top with left N3

Lowest both eyes second bottom N5

You would write Left N3 Right N5 both N5.

The Swinging Light Test (includes Pupil Light reflex and the consensual light reflex)
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Indications

To test for a relative afferent pupillary defect (RAPD)

The ‘swinging light test’ is used to detect a relative afferent pupil defect (RAPD): a means of detecting
differences between the two eyes in how they respond to a light shone in one eye at a time. The test
can be very useful for detecting unilateral or asymmetrical disease of the retina or optic nerve (but only
optic nerve disease that occurs in front of the optic chiasm).

The physiological basis of the RAPD test is that, in healthy eyes, the reaction of the pupils in the right
and left eyes are linked. In other words, a bright light shone into one eye leads to an equal constriction
of both pupils. When the light source is taken away, the pupils of both eyes enlarge equally. This is
called the consensual light reflex.

To understand how the pupils react to light, it is important to understand the light reflex pathway
(Figure (Figure1).1). This pathway has two parts.

1. The afferent part of the pathway (red) refers to the nerve impulse/message sent from the pupil
to the brain along the optic nerve when a light is shone in that eye.
2. The efferent part of the pathway (blue) is the impulse/message that is sent from the mid-brain
back to both pupils via the ciliary ganglion and the third cranial nerve (the oculomotor nerve),
causing both pupils to constrict, even though only one eye is being stimulated by the light.

Figure 1

The light reflex pathway showing the afferent path (red) and the efferent path (blue)
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A positive RAPD means there are differences between the two eyes in the afferent pathway due to
retinal or optic nerve disease. If the light used is sufficiently bright, even a dense cataract or corneal scar
will not give a RAPD if the retina and optic nerve are healthy. Indeed, the test can be used to assess the
health of the retina and optic nerve behind a dense cataract, for example.

In glaucoma, if other tests of visual function (e.g., visual fields) are not possible, detecting a RAPD can be
very useful as it indicates that there is more optic nerve damage in one eye than in the other, even if the
visual acuity in both eyes is equal.

NOTE: If the glaucomatous damage is equal in the two eyes, there will be no RAPD, however severe the
damage is.

The swinging light test

In a normal swinging light test (i.e. there is no RAPD) the pupils of both eyes constrict equally regardless
of which eye is stimulated by the light (Figure (Figure2).2). In an abnormal swinging-light test (i.e. there
is a RAPD) there is less pupil constriction in the eye with the retinal or optic nerve disease (Figure
(Figure33).

Steps

• Use a bright torch which can be focussed to give a narrow, even beam of light. Perform the test
in a semi-darkened room. If the room is too dark it will be difficult to observe the pupil
responses, particularly in heavily pigmented eyes.
• Ask the patient to look at a distant object, and to keep looking at it. Use a Snellen chart, or a
picture. This is to prevent the near-pupil response (a constriction in pupil size when moving
focus from a distant to a near object). While performing the test, take care not to get in the way
of the fixation target.
• Move the whole torch deliberately from side to side so that the beam of light is directed directly
into each eye. Do not swing the beam from side to side around a central axis (e.g. by holding it
in front of the person's nose) as this can also stimulate the near response.
• Keep the light source at the same distance from each eye to ensure that the light stimulus is
equally bright in both.
• Keep the beam of light steadily on the first eye for at least 3 seconds. This allows the pupil size
to stabilise. Note whether the pupil of the eye being illuminated reacts briskly and constricts
fully to the light. Also note what happens to the pupil of the other eye: does it also constrict
briskly?
• Move the light quickly to shine in the other eye. Again, hold the light steady for 3 seconds. Note
whether the pupil being illuminated stays the same size, or whether it gets bigger. Note also
what happens to the other eye.
• As there is a lot to look at, repeat the test, observing what happens to the pupils of both eyes
when one and then the other eye is illuminated.

When the test is performed on someone with unilateral or asymmetrical retinal or optic nerve disease, a
RAPD should be present (Figure (Figure3).3). The following happens:
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• When the light is shone into the eye with the retinal or optic nerve disease, the pupils of both
eyes will constrict, but not fully. This is because of a problem with the afferent pathway.
• When the light is shone into the other, normal (less abnormal) eye, both pupils will constrict
further. This is because the afferent pathway of this eye is intact, or less damaged than that of
the other eye.
• When the light is shone back into the abnormal eye, both pupils will get larger, even the pupil in
the normal eye.
• It does not matter whether you start with the eye you think has the greater problem or the
healthier eye: as long as the light is switched from one eye to the other and back again the signs
should become apparent.

Sometimes the RAPD is obvious, as the pupil in the (most) affected eye very obviously gets larger when
that eye is illuminated. But the signs can be more subtle.

Causes of RAPDs

Common causes of unilateral optic nerve disorders that can be associated with a RAPD include
ischaemic optic neuropathy, optic neuritis, optic nerve compression (orbital tumours or dysthyroid eye
disease), trauma, and asymmetric glaucoma. Less common such causes include infective, infiltrative,
carcinomatous, or radiation optic neuropathy. A RAPD is an extremely important localising clinical sign
that can be detected by a simple, quick, non-invasive clinical test, provided that the test is performed
carefully and correctly.

U-Tubes

https://www.youtube.com/watch?v=WrNYqNH3b3A Short summary

https://www.youtube.com/watch?v=wpG62cJMJcE&feature=emb_rel_pause Better and fuller

explanation.

Source (Community Eye Health International Centre for Eye Health by David C Broadway)
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5. Confrontational visual field eye tests

Positioning

The patient should be seated in a chair or on the examination table in an adequately lit room. The
examiner should assume a position directly across from the patient at an arm's length, so that their eyes
are level.
Visual Fields Confrontation Testing

1. Visual fields: The normal visual field for each eye extends out from the patient in all directions,
with an area of overlap directly in front. Field cuts refer to specific regions where the patient has
lost their ability to see. This occurs when the transmitted visual impulse is interrupted at some
point in its path from the retina to the visual cortex in the back of the brain. You would, in
general, only include a visual field assessment if the patient complained of loss of sight; in
particular "blind spots" or "holes" in their vision. Visual fields can be crudely assessed as follows:

1. The examiner should be nose to nose with the patient, separated by approximately 8 to
12 inches.
2. Each eye is checked separately. The examiner closes one eye, and the patient closes the
one opposite. The open eyes should then be staring directly at one another.
3. The examiner should move their hand out towards the periphery of his/her visual field
on the side where the eyes are open. The finger should be equidistant from both
persons.
4. The examiner should then move the wiggling finger in towards them, along an imaginary
line drawn between the two persons. The patient and examiner should detect the finger
at the same time.
5. The finger is then moved out to the diagonal corners of the field and moved inwards
from each of these directions. Testing is then done starting at a point in front of the
closed eyes. The wiggling finger is moved towards the open eyes.
6. The other eye is then tested.

Meaningful interpretation is predicated upon the examiner having normal fields, as they are using
themselves for comparison.

If the examiner cannot seem to move their finger to a point that is outside the patient's field don't
worry, as it simply means that their fields are normal.

Interpretation: This test is rather crude, and it is quite possible to have small visual field defects that
would not be apparent on this type of testing. Prior to interpreting abnormal findings, the examiner
must understand the normal pathways by which visual impulses travel from the eye to the brain.

Recording confrontation visual fields

Views
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Recording confrontation visual field results.

A. Normal result: the patient counts fingers in all quadrants of both eyes.

B. Bitemporal hemianopia: the patient fails to count fingers in the temporal quadrants of each eye.

C. Homonymous hemianopia: the patient fails to count fingers in the temporal quadrants of one eye and
the nasal quadrants of the other eye. CF = Counts Fingers.

(American Academy of Ophthalmology Comprehensive Ophthalmology )

https://www.youtube.com/watch?v=Vp7LBSe7DcI

https://www.youtube.com/watch?v=GMyj_8wdIyQ better u tube

http://www.youtube.com/watch?v=Gh1jGh1dcsA an alternative

Remember

• your eye height should be the same.

• your fingers should be halfway between you and the patient.
• patient must look at your nose.
• close your eye which is opposite to patient’s closed eye.
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6. Extraocular Movements (CN III, IV, VI)

Check extraocular movements (eye movements) by having the patient look in all directions without
moving their head and ask them if they experience any double vision. Test smooth pursuit by having the
patient follow an object moved across their full range of horizontal and vertical eye movements.

Test convergence movements by having the patient fixate on an object as it is moved slowly towards a
point right between the patient's eyes. Also, observe the eyes at rest to see if there are any
abnormalities such as spontaneous nystagmus (see below)or dysconjugate gaze (eyes not both fixated
on the same point) resulting in diplopia (double vision)

Saccades are eye movements used to rapidly refixate from one object to another. The examiner can test
saccades by holding two widely spaced targets in front of the patient (such as the examiner's thumb on
one hand and index finger on the other) and asking the patient to look back and forth between the
targets.

Normally, rhythmic eye movements called nystagmus occur consisting of an alternating slow phase with
slow pursuit movements in the direction of strip movement, and a rapid phase with quick refixations
back to midline.

In comatose or severely lethargic patients, the vestibulo-ocular reflex can be used to test whether
brainstem eye movement pathways are intact. The oculocephalic reflex, a form of the vestibulo-ocular
reflex, is tested by holding the eyes open and rotating the head from side to side or up and down. These
manoeuvres obviously should not be performed in cases of head injury or other cases of suspected
cervical spine trauma unless complete cervical spine films are normal. The reflex is present if the eyes
move in the opposite direction of the head movements, and it is therefore sometimes called doll's eyes.
Note that in awake patients, doll's eyes are usually not present because voluntary eye movements mask
the reflex. Thus, the absence of doll's eyes suggests brainstem dysfunction in the comatose patient but
can be normal in the awake patient. Another, more potent stimulus of the vestibulo-ocular reflex used
to evaluate comatose patients is caloric stimulation.

What is Being Tested?

Careful testing can often identify abnormalities in individual muscles or in particular cranial nerves
(oculomotor, trochlear, or abducens) in their course from the brainstem to the orbit, in the brainstem
nuclei, or finally, in the higher-order centres and pathways in the cortex and brainstem that control eye
movements.

Spontaneous nystagmus can indicate toxic or metabolic conditions such as drug overdose or alcohol
intoxication, or peripheral or central vestibular dysfunction.

The medial and lateral rectus muscles are described first, as their functions are very straight forward:
Lateral rectus: Abduction (i.e. lateral movement along the horizontal plane)
Medial rectus: Adduction (i.e. Medial movement along the horizontal plane)
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The remaining muscles each causes movement in more than one direction (e.g. some combination of
elevation/depression, abduction/adduction, intorsion/extorsion). This is since they insert on the eyeball
at various angles, and in the case of the superior oblique, thru a pulley. Review of the origin and
insertion of each muscle sheds light on its actions (see links @ the end of this section). The net impact of
any one EOM is the result of the position of the eye and the sum of forces from all other contributing
muscles.

Specific actions of the remaining EOMs are described below. The action which the muscle primarily
performs is listed first, followed by secondary and then tertiary actions.
Inferior rectus: depression, extorsion and adduction.
Superior rectus: elevation, intorsion and adduction
Superior oblique: intorsion, depression and abduction
Inferior oblique: extorsion, elevation and abduction

The muscles, in turn, are innervated by 3 different cranial nerves. Patterns of innervations are as
follows:

Cranial 4 (Trochlear): innervates the superior oblique

Cranial Nerve 6 (Abducens): innervates the lateral rectus
Cranial Nerve 3 (Oculomotor): innervates all the remaining muscles (i.e. medial rectus, inferior oblique,
superior rectus and inferior rectus).

You can remember this via the mnemonic: "SO-4, LR-6, All the rest 3" (i.e. Superior Oblique by CN 4,
Lateral rectus by CN 6, and all the other EOMs by CN 3).

In the setting of an eye movement problem, isolating which muscle or CN is the culprit can be tricky.
When trying to isolate a problem, it can help to check movement in the direction in which that muscle is
the primary mover. This can be assessed as follows:

a. Superior oblique: Depresses the eye when looking medially.

b. Inferior oblique: Elevates the eye when looking medially.
c. Superior rectus: Elevates the eye when looking laterally.
d. Inferior rectus: Depresses the eye when looking laterally.
e. Medial rectus: Adduction when pupil moving along horizontal plane.
f. Lateral rectus: Abduction when pupil moving along horizontal plane.

Practically speaking, cranial nerve testing is done such that the examiner can observe eye movements in
all directions. The movements should be smooth and coordinated. To assess, proceed as follows:

1. Stand in front of the patient.

2. Ask them to follow your finger with their eyes while keeping their head in one position.
3. Using your finger, trace an imaginary "H" or rectangular shape in front of them, making sure that
your finger moves far enough out and up/down so that you're able to see all appropriate eye
movements (i.e. lateral and up, lateral down, medial down, medial up).
4. At the end, bring your finger directly in towards the patient's nose. This will cause the patient to
look cross-eyed and the pupils should constrict, a response referred to as accommodation.
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OM or extra ocular movements,

Eye movements use similar names as other movements with

inferior being downward,

superior being upward,

lateral movements described adduction moving toward the nose (nasal)and abduction away from the
nose (temporal).

Convergence, which is the movement of both eyes toward the nose (convergence) or away from the
nose (divergence). Smooth convergence and divergence are important in the near focusing system.

With the patient seated and focused on a point about 16 inches away. The eyes should be still as the
patient focuses. A small rhythmic movement, called nystagmus, is a sign of a central problem. It is often
associated central nervous system problems like Multiple Sclerosis. It is a frequent early sign of the
disorder. It is also closely linked to the vestibular system and the patient might report dizziness. When
congenital, the brain adjusts to movements as in the video below.

9 points of primary gaze are assessed having the patient follow a point to left/right/up/down/up
left/low left/upright/low right. The eyes should move together through all these points.
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Reference (http://www.neuroexam.com/neuroexam/content19.html)

U tube which is reasonable

https://www.youtube.com/watch?v=X0uM2NfO3Bk

What do you need to know for exam- You must be able to perform the examination and interrupt a
simple abnormality like the CN vi (Lateral Rectus) palsy.
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7. Accommodation Test

The pupillary response to accommodation. Normally, the pupils constrict while fixating on an object
being moved from far away to near the eyes.

What is Being Tested?

Direct response (pupil illuminated). The direct response is impaired in lesions of the ipsilateral optic
nerve, the pretectal area, the ipsilateral parasympathetics traveling in CN III, or the pupillary constrictor
muscle of the iris.

Consensual response (contralateral pupil illuminated). The consensual response is impaired in lesions
of the contralateral optic nerve, the pretectal area, the ipsilateral parasympathetics traveling in CN III, or
the pupillary constrictor muscle.

Accommodation (response to looking at something moving toward the eye). Accommodation is

impaired in lesions of the ipsilateral optic nerve, the ipsilateral parasympathetics traveling in CN III, or
the pupillary constrictor muscle, or in bilateral lesions of the pathways from the optic tracts to the visual
cortex. Accommodation is spared in lesions of the pretectal area.

U-tube

http://www.youtube.com/watch?v=p_xLO7yxgOk explains the mechanics behind the test

http://www.youtube.com/watch?v=TFcCHsY1OUo good simple demonstration
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9. Colour testing

A set of images called the Ishihara colour plates is one of the most common and reliable tests.

Simply look at the images, which have numbers embedded in dots of colour. The numbers are a
different colour than the background. If you cannot see the numbers, you’re probably colour-blind.
School kids often take the Ishihara test as a classroom activity. It is that easy. And can be fun.

But for anyone taking this test, it is important to understand what it means to be colour blind. The
condition is uncommon and it is rarely serious. Testing positive is no reason to panic.

“It very minimally impacts everyday life,” says Jane C. Edmond, MD, an ophthalmologist at Texas
Children’s Hospital.

The term itself is a little misleading. With rare exception, people who are colour blind do not live in a
colourless world. They see most colours clearly.

Colour blindness occurs when cone cells, located in the retinal tissue at the back of the eye, do not
function or are damaged. There are two main kinds of colour blindness:

• Red/green colour blindness, the most common type, is congenital or inherited. It’s far more
common in males than females, but still very rare. It affects 5 to 8 percent of males, and 0.5
percent of females. For people with red/green colour blindness, reds and greens look like each
other as a kind of brownish, muted tone. There is also a blue/yellow type of colour blindness,
but it is even more rare.
• A second, and less common, kind of colour blindness is acquired, or related to an eye disease or
condition. Retinal or optic nerve disorders are most likely to cause this kind of colour blindness.
In these cases, symptoms such as overall failing vision or persistent dark or white spots may be
noticed first. An ophthalmologist may test for colour blindness to help diagnose the problem.
The doctor may start with an Ishihara screening test and, if that is positive, move to more
sophisticated testing.
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Many versions of the Ishihara colour blindness test have been produced. This example has lines that the
person being tested can trace. This version of the test works for people who cannot read letters or
numbers.

Should You Be Tested for Colour Blindness?

The American Academy of Ophthalmology does not have formal recommendations for colour blindness
testing. You can have red/green colour blindness and function well without even knowing it, according
to Dr. Edmond.

“For the red-green patient, their visual acuity is totally normal, their eye exam is normal,” Dr. Edmond
says. “It’s not part of most doctors’ routine screening.”

If there is a family history of colour blindness, or if you’re suspicious for yourself or your child, there’s no
harm in taking the Ishihara test.

The Ishihara test is named for Japanese ophthalmologist Ishihara Shinobu, a professor at the University
of Tokyo who developed the screening in 1918 for the military. Though devised nearly a century ago, the
Ishihara test is commonly used today and works for most people. In some instances, other tests are
needed, such as for people whose eyesight is so poor, they cannot see any of the image well, regardless
of colour.

(Leer en Español: Cómo se Hacen las Pruebas Para Detectar el Daltonismo

Written By: Kate Rauch Reviewed By: Jane C Edmond MD Aug. 25, 2017)

U-Tube links. None are ideal but they give you an idea. The second is a demonstration and reasonable.

https://www.youtube.com/watch?v=emEKDww0iac

https://www.youtube.com/watch?v=hwGDOJyZJnk
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10. Amsler Grid testing

Amsler Grid Eye Test

Instructions for using the Amsler Grid.

To test central or macular vision, an Amsler grid (Fig. 2.12), which is like a piece of graph paper with a
central fixation point, can be viewed by the patient at near proximity. The patient fixates on the central
dot with near correction and is asked whether all the lines are straight and whether any parts are
missing, bent, or blurry.

The patient may perceive abnormal areas on the grid that might correspond with visual field deficits.
Amsler grid testing is particularly helpful in detecting central and paracentral field defects. Small deficits
(affecting only a couple of boxes) point to macular disease and may not be detected on computerized
perimetry. Unlike neurologic processes, maculopathies associated with a thickening or surface
irregularity of the retina can produce a distortion (bending of the lines) in the grid pattern
(metamorphopsia). The results of Amsler grid testing can be documented with a convention like that of
confrontation visual field testing.
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Amsler grid

Testing your eyes with an Amsler grid is easy and takes only a few minutes. Here are the basic steps:

1. Test your eyes under normal room lighting used for reading.
2. Wear eyeglasses you normally wear for reading (even if you wear only store-bought reading
glasses.
3. Hold the Amsler grid approximately 14 to 16 inches from your eyes.
4. Test each eye separately: Cup your hand over one eye while testing the other eye.
5. Keep your eye focused on the dot in the centre of the grid and answer these questions:
o Do any of the lines in the grid appear wavy, blurred, or distorted?
o Do all the boxes in the grid look square and the same size?
o Are there any "holes" (missing areas) or dark areas in the grid?
o Can you see all corners and sides of the grid (while keeping your eye on the central
dot)?
6. Switch to the other eye and repeat.

(DAVID B. ELLIOTT, JOHN FLANAGAN, in Clinical Procedures in Primary Eye Care (Third Edition), 2007)