Ophthalmology Examination

By MBBS Gang
1. Corneal Reflex
Greet and introduce yourself → Confirm patient details (by asking their name) → Explain
the examination process and assure them that it will not cause harm → Take verbal
consent → Ask the patient to remove glasses (if any) → Make sure the fan is off in the
room → Prepare a sterile cotton wick and inform the patient that you are going to
slightly touch it to their eyeball and it won’t be painful → Ask the patient to look straight
ahead → Hold the sterile cotton-wick near the patient’s eye and gently touch the
peripheral cornea near the limbus with the cotton-wick tip → Observe the patient’s
response (a normal response is a bilateral blink reflex) → Repeat the process in the
other eye.

Some conditions where corneal reflex is absent are:

• Keratitis and keratoconjunctivitis (viral)

• Trigeminal neuralgia
• Herpes zoster Ophthalmicus
• Bell’s palsy
• Brain stem lesion
• Anaesthetic or anticholinergic agents
 2. Projection of Rays (PR)
Greet and introduce yourself → Confirm patient details (by asking their name) → Explain
the examination process and assure them that it will not cause harm → Take verbal
consent → Ask the patient to remove glasses (if any) → Make sure the room is dark or
dimly lit (if the light cannot be turned off, shade one side with an exam sheet) → Ask the
patient to cover one eye firmly with their hands → Tell them to look straight ahead and
fixate on a distant object (if the patient has low vision, ask them to focus on their
outstretched hand) → Now use a bright light source and hold it with an extended hand
(so the patient doesn’t guess your hand movements) → Now throw light in all 4
quadrants in random fashion while switching off the light when taking it from one side to
another (remind not to cross in front of the light as we check peripheral retinal sensation
in this test) → Ask the patient where the light is coming from when you shine light from
any quadrant → If the patient can tell the directions of light, PR sensation is optimum in all
4 quadrants.

*Note: To switch the light on and off, simply bend your wrist and turn away the light
source head to the opposite side out of the vision field while moving it from one side to
another (e.g., from temporal to nasal).
 3. Ocular Field Assessment by Confrontation Method
Greet and introduce yourself → Confirm patient details (by asking their name) → Explain
the examination process → Take verbal consent → Ensure the room is illuminated
enough → Sit facing the patient 1m away at the same eye level → Now start peripheral
visual field assessment by telling the patient to cover one (say left) eye and examiner
covers their opposite (say right) eye (as your right is the patient’s left) → Now tell the
patient to look straight at your nose and not move their neck or head → Then extend
your free left hand out of your visual field and place it horizontally, now slowly bring it
near to your face while flickering your index and middle finger together → Ask the
patient if they can appreciate your moving fingers at the same time when you also started
seeing it →

If yes, then at that field (temporal field projecting over Nasal retina) the patient’s field of
vision is normal compared to the examiner.

If no, ask when they are appreciating the object. In that case, the field of vision is
impaired compared to the examiner.

Now with your free left hand do it again while extending your hand vertically up and
down at 90 degrees, +45 degrees and -45 degrees and compare the field of vision.

→ Thus, perform it on Nasal field of vision of patient’s left eye. Here, covers your same eye
with your left hand instead of right and extend your free right hand horizontally and
perform the above step and note when the patient is appreciating the moving fingers.

Now with your free right hand do it again while extending your hand vertically up and
down at 90 degrees, +45 degrees and -45 degrees and compare the field of vision.

Repeat it on the right eye by closing the patient’s left eye. Tell results to sir/patient.
Types of visual field defects
Bitemporal hemianopia: loss of the temporal visual field in both eyes resulting in central
tunnel vision. Bitemporal hemianopia typically occurs as a result of optic chiasm
compression by a tumour (e.g. pituitary adenoma, craniopharyngioma).
Homonymous field defects: affect the same side of the visual field in each eye and are
commonly attributed to stroke, tumour, abscess (i.e. pathology affecting visual
pathways posterior to the optic chiasm). These are deemed hemianopias if half the
vision is affected and quadrantanopias if a quarter of the vision is affected.
Scotoma: an area of absent or reduced vision surrounded by areas of normal vision.
There is a wide range of possible aetiologies including demyelinating disease (e.g.
multiple sclerosis) and diabetic maculopathy.
Monocular vision loss: total loss of vision in one eye secondary to optic nerve pathology
(e.g. anterior ischaemic optic neuropathy) or ocular diseases (e.g. central retinal artery
occlusion, total retinal detachment).

Blind spot
A physiological blind spot exists in all healthy individuals as a result of the lack of
photoreceptor cells in the area where the optic nerve passes through the optic disc. In
day-to-day life, the brain does an excellent job of reducing our awareness of the blind
spot by using information from other areas of the retina and the other eye to mask the
defect.
 4. Blind Spot Assessment
1. Sit directly opposite the patient, at a distance of around 1 metre.
2. Ask the patient to cover one eye with their hand.
3. If the patient covers their right eye, you should cover your left eye (mirroring the
patient).
4. Ask the patient to focus on part of your face (e.g. nose) and not move their head or
eyes during the assessment. You should do the same and focus your gaze on the
patient’s face.
5. Using a red hatpin (or alternatively, a cotton bud stained with fluorescein/pen with a
red base) start by identifying and assessing the patient’s blind spot in comparison to the
size of your own. The red hatpin needs to be positioned at an equal distance between
you and the patient for this to work.
6. Ask the patient to say when the red part of the hatpin disappears, whilst continuing to
focus on the same point on your face.
7. With the red hatpin positioned equidistant between you and the patient, slowly move
it laterally until the patient reports the disappearance of the top of the hatpin. The blind
spot is normally found just temporal to central vision at eye level. The disappearance of
the hatpin should occur at a similar point for you and the patient.
8. After the hatpin has disappeared for the patient, continue to move it laterally and ask
the patient to let you know when they can see it again. The point at which the patient
reports the hatpin re-appearing should be similar to the point at which it re-appears for
you (presuming the patient and you have a normal blind spot).
9. You can further assess the superior and inferior borders of the blind spot using the
same process.
Causes of an enlarged blind spot
An enlarged blind spot is typically associated with a swollen optic disc (papilloedema)
which is most often caused by raised intracranial pressure (e.g., brain tumour,
hypertensive crisis, intracranial haemorrhage).
 5. Extra-Ocular Movements
Greet and introduce yourself → Confirm patient details (by asking their name) → Explain
the examination process → Take verbal consent → Ensure the patient’s eye level is at the
same level as the examiner and the room must be illuminated enough → Now place a
colourful pen 2ft apart in front of the patient at eye level in the central portion → Tell the
patient to look at it and ask if they see one or two pens (if 2, then diplopia is present)
→ Now tell the patient to follow the pen’s movement with their eyes while keeping their
head still (no neck or head movements) → Now move the pen slowly in an “H” fashion
starting from the center and notice the symmetrical and coordinated eye movements
→ After that, ask the patient if at any point they saw two pens → Result: normally eye
movements are in full range in all coordinates.

The four ocular movement quadrants are:

1. Superior: This quadrant is located above the center of the visual field, and eye
movements towards this quadrant are called upward gaze or elevation.
2. Inferior: This quadrant is located below the center of the visual field, and eye
movements towards this quadrant are called downward gaze or depression.
3. Nasal: This quadrant is located towards the nose side of the visual field, and eye
movements towards this quadrant are called adduction.
4. Temporal: This quadrant is located towards the ear side of the visual field, and eye
movements towards this quadrant are called abduction.
 6. Digital Tonometry
Greet and introduce yourself → Confirm patient details (by asking their name) → Explain
the examination process and assure them that it will not cause harm → Take verbal
consent → Ask the patient to sit in a chair and lean their head back against the headrest
(Make sure the head is supported. If a headrest is not present, ask the patient to stiffen
their neck and not move their head) → Sanitize your hands → Ask the patient to look
down without moving their neck and close their eye (thus avoiding the tarsal plate) →
Now advise the patient to breathe normally and not hold their breath or tense up during
tonometry (this may give a false raise in IOP) → Thereafter rest your middle fingers over
the left/right side of the patient’s forehead depending on which side you are checking
first → Then place your index fingers over the globe → Use one index finger to give slight
pressure on one side and keep the other index pulp stationary → Now try to feel the
fluctuations over the stationary index finger pulp → Do the same for the other eye.

Result:

1. If fluctuations are absent/

feeble and the eyeballs feel
firm / hard, → IOP is raised.
2. If identification is more
pronounced (only mention if
asked) and the eyeballs feel
soft like a partially filled
water bag → IOP is low.

Extra steps in applanation (Goldmann’s) and indentation (Schiotz) tonometry:

• Instillation of anaesthetic eye drops: Place anaesthetic eye drops in the patient’s
eye to numb the surface of the eye and make the procedure more comfortable for
the patient. Wait for a few minutes to allow the drops to take effect.
• Calibration of the tonometer: Calibrate the tonometer according to the
manufacturer’s instructions.
• Measurement: Place the tonometer tip against the patient’s cornea and measure
intraocular pressure. Repeat on the other eye if necessary.
• Record keeping: Record the measurement in the patient’s chart or record sheet.
 7. Visual Acuity + Perception of Light (PL)
Greet and introduce yourself → Confirm patient details (by asking their name) → Explain
the examination process and assure them that it will not cause harm → Take verbal
consent → Now ask if the patient normally wears glasses (if yes, for far or near vision) →
Now make the patient look at Snellen’s chart from a 6m distance # → Then ask the
patient to read down from top to bottom as far as they can with one eye closed by one
hand (tell the patient not to squint or lean forward while reading the chart) → Now
based on whether the patient can or can’t read the first top line of words on the chart,
the process is different.
[# - In small set-up, 6m distance achieved by using mirror and at least a distance of 3m.
Seeing in mirror reflection gives 3m x 2 = 6m distance]

If they can read the first line of words on the chart → Do visual acuity in both eyes
separately with and without specs → Note down the number written on chart rows’
ending each time at the point when the patient cannot read anymore
(6[fixed]/60[changes]) → After that check near vision using Jaeger’s chart at a 25cm
distance and note the vision score on both eyes with and without specs.

Now perform a Pinhole test in both eyes by placing a 1mm radius pinhole in front of the
eye alternatively closing one eye → Ask the patient to read (both Snellen’s and Jaeger’s
chart ideally, but one is sufficient) through the hole.

1. Improved vision (presence of refractive error) → Vision will improve with

spectacles
2. Not improved (presence of some other ocular pathology) → Vision will not
improve with spectacles
If they cannot read the first line of words on the chart → Move the patient closer to the
chart 1m at a time and ask if they can read the first line of words → Note the vision if the
patient reads it (6[changes]/60[fixed]) → Now if the patient can’t see from a 1m distance
→ Perform a Counting Finger test at 3ft, 2ft, 1ft and note where the patient can count
properly (Resultant vision = CF 3ft, 2ft, 1ft) → If they still can’t count fingers (-ve CF test)
→ Go for a Hand Movement test by placing your hand and moving it from a 1m distance
(if perceived vision = HM +ve at 1m) → If they can’t perceive then take your hand near
their face (-ve HM test if still can’t perceive, if perceived HM +ve) → Now lastly do
Perception of Light test → Make sure to dim the light of room or ask to turn off the light
→ Then start by illuminating their eyes from side to front → Ask the patient if they can
perceive light → Vision = PL +ve (if light perceived) and PL -ve (if light not perceived).
 8. Pupillary Reflex
Greet and introduce yourself → Confirm patient details (by asking their name) → Explain
the examination process and assure them that it will not cause harm → Take verbal
consent → Make sure the room light is dim → Ask the patient to remove glasses if any
then inspect the pupil (size, shape, symmetry*) → Now ask the patient to fix their vision
at any distant object and advise that the light may be uncomfortable so don’t focus their
vision at the light source → Now ask the patient to keep one of their hand’s ulnar border
over their nose to act as a light guard for the other eye (you can also place your own
hand if the patient doesn’t understand what you are asking) → Now shine a light source
(placed at 2ft distance) in one eye from sideways and slowly move it towards the pupil then
rapidly move it away from the pupil (check direct reflex on the testing eye and indirect
reflex over the other light-guarded eye) → Do the same for the other eye (compare the
pupil reaction [fast/brisk] to light of both eyes) → Now perform a swinging light test
(usually not necessary unless specifically asked to do so) → Ask the patient to remove
their hand from their face → Now tell them again to fix their vision at a distant object →
Move the light source (placed at 1ft distance) rapidly from one eye to another eye →
Look for constricted pupils in both eyes (in afferent path pathology e.g. optic nerve,
relative dilation to light will appear on affected eye).
Inspect the patient’s pupils for abnormalities

1. Pupil Normal pupil size varies between individuals and depends on lighting
size conditions (i.e., smaller in bright light, larger in the dark).
Pupils can be smaller in infancy and larger in adolescence, then often
smaller again in the elderly.
2. Pupil Note any asymmetry in pupil size (anisocoria). This may be longstanding
symmetry and physiological or be due to acquired pathology. If the difference in
pupil size becomes greater in bright light such as
when facing a window in daylight, this would suggest that the larger pupil
is the pathological one. This is because the normal pupil will constrict in
brighter light accentuating the difference in size. If the difference is more
pronounced in dim lighting, this would imply the smaller pupil is abnormal
as the larger pupil would then dilate while the pathologically small pupil
remains the same size.
Examples of asymmetry include a larger pupil in oculomotor nerve palsy
and a smaller one in Horner’s syndrome.
3. Pupil Pupils should be round. Abnormal shapes can be congenital or due to
shape pathology (e.g., posterior synechiae associated with uveitis) or previous
trauma and surgery.
Peaked pupils in the context of trauma are suggestive of globe rupture
(the peaked appearance is caused by the iris plugging the leak).
4. Pupil Asymmetry in pupillary colour is most commonly due to congenital
colour disease. In rare cases, asymmetry of colour can suggest Horner’s
syndrome, with the paler washed-out iris being pathological.

9. Accommodation Reflex
1. Ask the patient to focus on a distant object (clock on the wall/light switch).
2. Place your finger approximately 20-30cm in front of their eyes (alternatively, use the
patient’s own thumb).
3. Ask the patient to switch from looking at the distant object to the nearby
finger/thumb.
4. Observe the pupils, you should see constriction and convergence bilaterally.
 10. Purkinje-Samson Images

Normally, when a strong beam of light is shown to the eye, 4 images (Purkinje images)
are formed from the 4 different reflecting surfaces, viz. anterior and posterior surfaces
of cornea and anterior and posterior surfaces of lens.
• In patients with mature cataract, the fourth image (formed by the posterior
surface of the lens) is absent, i.e., 3 Purkinje images are formed.
• In aphakia, the third and fourth Purkinje images (formed by the anterior and
posterior surface of the lens) are absent, i.e., only 2 images are formed.
[Note: This test does not have much significance and thus is not frequently employed in
clinical practice. However, it is described as a tribute to the original worker who used
this test to diagnose mature cataract and aphakia.]
At least four Purkinje images are usually visible in the normal eye.
The 1st Purkinje image (P1) is the reflection from the outer surface of the cornea.
The 2nd Purkinje image (P2) is the reflection from the inner surface of the cornea.
The 3rd Purkinje image (P3) is the reflection from the outer (anterior) surface of the lens.
The 4th Purkinje image (P4) is the reflection from the inner (posterior) surface of the
lens.
• P1 is brightest and overlaps P2.
• P3 is largest.
• P4 is brighter than P3, but inverted.
• P1 and P4 may be used in eye tracking
 11. Colour vision assessment
Colour vision can be assessed using Ishihara plates, each of which contains a coloured
circle of dots. Within the pattern of each circle are dots which form a number or shape
that is clearly visible to those with normal colour vision and difficult or impossible to see
for those with a red-green colour vision defect.
How to use Ishihara plates
If the patient normally wears glasses for reading, ensure these are worn for the exam.
1. Ask the patient to cover one of their eyes.
2. Then ask the patient to read the numbers on the Ishihara plates. The first page is
usually the ‘test plate’ which does not test colour vision and instead assesses contrast
sensitivity. If the patient is unable to read the test plate, you should document this.
3. If the patient is able to read the test plate, move through all of the Ishihara plates,
with the patient to identifying the number on each. Once the test is complete, document
the number of plates the patient identified correctly, including the test plate (e.g., 13/13).
4. Repeat the assessment on the other eye.
 12. Assessment of strabismus

a. Light reflex test (a.k.a. corneal reflex test or Hirschberg test)

1. Ask the patient to focus on a target approximately half a metre away whilst you shine
a pen torch towards both eyes.
2. Inspect the corneal reflex on each eye: If the ocular alignment is normal, the light
reflex will be positioned centrally and symmetrically in each pupil.
Deflection of the corneal light reflex in one eye suggests a misalignment.
b. Cover test

The cover test is used to determine if a heterotropia (i.e., manifest strabismus) is

present.
1. Ask the patient to fixate on a target (e.g., light switch).
2. Occlude one of the patient’s eyes and observe the contralateral eye for a shift in
fixation:
• If there is no shift in fixation in the contralateral eye, while covering either eye, the
patient is orthotropic (i.e., normal alignment).
• If there is a shift in fixation in the contralateral eye, while covering the other eye,
the patient has a heterotropia.
3. Repeat the cover test on the other eye.
The direction of the shift in fixation determines the type of tropia; the table below
describes the appropriate interpretation.
Interpretation of the cover test: