Performing Physical

Assessment of the Eye

It involves assessing the
functions, such as vision
(distant, near, color, and
peripheral), eye muscle
functioning, and pupils
reflexes, as well as
inspecting the external and
internal eye structures.
 Equipments
• Snellen’s Chart
• Color vision chart
• Ophthalmoscopes
• Penlight
• Cotton swab/ball
• Gloves if indicated
 HISTORY
• Remember to look at each history
component as it relates to the eyes.
• Ask the patient the following:
• Do you have…
– Vision loss?
– Eye pan?
– Double vision
– Eye tearing?
– Dry eyes?
– Eye drainage?
– Eye appearance changes?
– Blurred vision?
 HISTORY
• Have you noticed any changes in your vision
• Do you wear glasses or lenses?
• Have you ever had surgery? Injury?
• Have you ever seen spots or floaters, flashes
of light, or halos around the lights?
• Do you a history of recurrent eye infection?
• When was your last eye exam?
• Do you have a history of HTN or diabetes?
• What medications are currently taking?
• Do you take any prescribed or OTC eye
drops?
TESTING VISUAL ACUITY
1. Distance
– Have patient stand 20 ft from chart.
– Test each eye separately, having patient cover
opposite eye being tested, then together with
and without corrective lenses.
– Alternate method using pocket vision screener:
Have patient hold pocket vision screener about
14inches from eye and proceed testing as above.
• - (Myopia) nearsightedness
2. Near Vision
– have patient hold newsprint about 14 inches
away and read.
– Hyperopia ( farsightedness)
3. Color Vision
– have patient identify color bars on Snellen eye
chart
– have patient identify figure embedded in the
Ishihara chart.
– Colorblindness
4. Visual Fields
– stand in front of patient, face to face about 1-1/2
ft apart.
– Ask patient to fix gaze straight ahead and cover
one eye.
– Bring a pen or wiggle your finger in from four
different fields (superior, inferior, temporal, and
nasal).
– Have patient say “now” once fingers or object
are seen.
– Measure degree of peripheral vision using
patient’s fixed gaze as a base.
– Diminished visual fields: Chronic glaucoma or
stroke.
– Peripheral vision intact in both eyes and all
fields.
ASSESSING THE EXTRAOCULAR
MUSCLES
1. Corneal Light Reflex Test
– Shine light directly in patient’s eyes; note position of
the light reflection off the cornea in each eye.
– Light should be seen symmetrically on each cornea.
– Exotopia (divergent strabismus)
– Congenital exotropia
2. Cover/ Uncover Test
– Cover patient’s eye and have patient focus on object
afar.
– Uncover eye and note any drifting.
– Gaze should be steady when eye is covered and
uncovered. No drifting.
– Weakness of extraocular muscles
3. Cardinal Fields of Gaze Test
– Stand in front of patient and instruct to fix gaze
straight ahead.
– Allow him to follow your finger or an object such as a
pen through the six cardinal fields.
– Note for any nystagmus.
 INSPECTING THE
EXTERNAL STRUCTURES
1. General Appearance
– Note clarity and parallel alignment.
– Eyes clear and bright, in parallel alignment.
– Glazed eyes: febrile state
2. Eyelashes
– Note distribution, inversion or eversion.
– Present and curving outward.
– No crusting or infestation.
– Absence of eyelashes: Alopecia universalis
– Lice or ticks at base of eyelashes; infestation
– Inverted eyelashes: Entropion
– Everted eyelashes: Extropion
3. Eyelids
– Note edema, lesions
– Upper eyelid normally covers one-half of upper
iris
– palpebral fissures symmetrical eyelids in contact
– Asymmetrical of lids: CN III damage, stroke
– Ptosis of both eyelids: Myasthenia Gravis
– Lesions f eyelids: Basal cell carcinoma, squamous
cell carcinoma, xanthelasma, chalazion,
hordeolum.
4. Eyeball
– note for protrusion.
– Exopthalmus
5. Lacrimal gland and Nasolacriminal Duct
– lacriminal glands located below eyebrow,
nasolacriminal ducts located on inner canthus or
eyes.
– Note for swelling, redness or drainage.
- swelling, redness, drainage, tenderness –
inflammation
6. Conjunctiva
– To examine bulbar conjunctiva, gently
pull lower lids down.
– To examine the palpebral conjunctiva,
use a q-tip and gently roll eyelid up.
– Note color, foreign objects.
– Acute allergic conjunctivitis
– Pterygium
– Pinguecula
– Benign growth: Papilloma
7. Sclera
– Note color of sclera.
– Reddish sclera diffuse episcleritis
– Icteric (yellow) sclera at the limbus:
elevated bilirubin (jaundice)
8. Cornea and lenses
– Shine a light on the cornea from an
oblique angle.
– Note clarity and abrasions.
– Corneal reflex: to test the corneal reflex
take a wisp of rolled cotton and gently
touch the cornea, or take a needle less
syringe filled with air and shoot a ff of
air over the cornea, note blinking and
tearing.
– Blinking reflex: brush your index finger
across patient’s eyelashes and note
blinking.
– Cloudy cornea; Vitamin A deficiency
– Lens Opacities: cataract
9. Iris
– note for color and shape
• bloodshot appearance or vessels; Iritis
10. Pupils
– note pupil size and equality
– test papillary reaction to light; have patient look
straight ahead while you bring light in from the side
over the eyes.
– Note reaction and speech in both eyes.
– Small, pinpoint pupils (miosis): brain injury to the
pons.
– Larger, dilated pupils (mydriasis): use of marijuana,
mydriatic eye drops.
11. Accommodation
– hold your finger or an object in font of patient from
a distance of about 1 inches from patient.
– Instruct patient to focus on finger or object while
you move finger or object closure to patient.
– Note convergence of eyes and constriction of pupils
as object gets closer.
– Poor convergence – exophthalmus
12. Anterior chamber
– have patient look straight ahead as you shine a light
from the side across the eye.
– Note clarity and shadowing from iris.
– Hypopyon – pus
 PALPATING THE EXTERNAL
STRUCTURES
1. Eyeball
– gently palpate below eyebrow and note
firmness or eyeball.
– Excessively firm or tender globe:
Glaucoma
2. Lacrimal Glands and Nasolacriminal Duct
– to palpate glands, gently palpate below
eyebrows on brows.
– To palpate ducts, glands, gently palpate
inner canthus of eyes.
– Swelling and tenderness; inflammation
PERFORMING AN OPTHALMIC
EXAMINATION
1. Red Reflex
– Stand about ft from patient at a 15-degree angle
from patient’s line of vision.
– Place index finger on lens wheel and turn wheel
as needed to focus.
– Keep free hands on patient’s forehead to
determine distance/ closeness to patient.
2. Optic Disc
– Move closer within inches from patient, turning
the lens wheel to focus as needed.
– Identify structures.
3. Blood Vessels
• - Arteries and veins originate from disc in
pairs, so make sure to note size, color and
crossings.