OCULAR EXAMINATION

• After the patient’s chief complaint or concern

has been identified
• and the history has been obtained, visual
acuity should be assessed.
• This is an essential part of the eye examination
and a measure
• against which all therapeutic outcomes are
based.
 VISUAL ACUITY

• Snellen chart is mostly used in this case.

• This chart is composed of a series of smaller rows
of letters and is used to test distance vision.
• The fraction 20/20 is considered the standard of
normal vision.
• Most people can see the letters on the line
designated as 20/20 from a distance of 20 feet.
• A person whose vision is 20/200 can see an object
from 20 feet away that a person whose vision is
20/20 can see from 200 feet away.
 CONT’D
• The patient is positioned at the proscribed
distance, usually 20 feet, from the chart and is
asked to read the smallest line that he or she
can see.
• The patient should wear distance correction
(eyeglasses or contact lenses) if required, and
each eye should be tested separately.
• The right eye is commonly tested first and then
the left.
 CONT’D
• If the patient is unable to read the 20/20 line, he or she is given a
pinhole occluder and asked to read again using the eye in
question.
• A makeshift occluder may be created by making a pinhole in an
index card and asking the patient to look through the pinhole.
• Squinting produces the same effect.
• Patients should be encouraged to read more letters and to guess,
if necessary.
• Often, patients avoid guessing and prefer not to try at all rather
than to make a mistake.
• The patient should be encouraged to read every letter if possible.
 CONT’D
• The visual acuity (VA) is recorded in the following way.
• If the patient reads all five letters from the 20/20 line with the right eye
(OD) and three of the five letters on the 20/15 line with the left eye (OS),
• the examiner writes OD 20/20, OS 20/15-2, or VA 20/20, 20/15-2.
• If the patient is unable to read the largest letter on the chart (the 20/200
line),
• the patient should be moved toward the chart or the chart moved
toward the patient, until the patient is able to identify the largest letter
on the chart.
• If the patient can recognize only the letter E on the top line at a distance
of 10 feet, the visual acuity would be recorded as 10′/200.
• If the patient is unable to see the letter E at any distance, the examiner
should determine if the patient can count fingers (CF).
 CONT’D
• The examiner holds up a random number of fingers and asks the
patient to count the number he or she sees.
• If the patient correctly identifies the number of fingers at 3 feet,
the examiner would record CF/3′.
• If the patient is unable to count fingers, the examiner raises one
hand up and down or moves it side to side and asks in which
direction the hand is moving.
• This level of vision is known as hand motions (HM).
• A patient who can perceive only light is described as having light
perception (LP).
• The vision of a patient who is unable to perceive light is described
as no light perception (NLP).
 DIRECT OPHTHALMOSCOPY

• A direct ophthalmoscope is a hand-held instrument with various plus

and minus lenses.
• The lenses can be rotated into place, enabling the examiner to bring the
cornea, lens, and retina into focus sequentially.
• The examiner holds the ophthalmoscope in the right hand and uses the
right eye to examine the patient’s right eye. The examiner switches to
the left hand and left eye when examining the patient’s left eye.
• During this examination, the room should be darkened, and the patient’s
eye should be on the same level as the examiner’s eye.
• The patient and the examiner should be comfortable, and both should
breathe normally.
• The patient is given a target to gaze on and is encouraged to keep
• both eyes open and steady.
 CONT’D
• When the fundus is examined, the vasculature comes
into focus first.
• The veins are larger in diameter than the arteries.
• The examiner should focus on a large vessel and then
follow it toward the midline of the body, which leads to
the optic nerve.
• The central depression in the disc is known as the cup.
• The normal cup is about one third of the disc.
• The size of the physiologic optic cup should be
estimated.
 CONT’D
• The periphery of the retina can be examined
by having the patient shift his or her gaze.
• The last area of the fundus to be examined
should be the macula, because this area is the
most light sensitive.
• The retina of a young person often has a
glistening effect, which is sometimes referred
to as a cellophane reflex.
 CONT’D
• The healthy fundus should be free of any lesions.
• The examiner should look for intraretinal hemorrhages, which
may appear as red or, if the patient has hypertension, may
look somewhat flame shaped.
• Lipid may be present in the retina of patients with
hypercholesterolemia or diabetes.
• This lipid has a yellowish appearance.
• The examiner looks for microaneurysms, which look like little
red dots, and nevi.
• The examiner should sketch the fundus and document any
abnormalities.
 INDIRECT OPHTHALMOSCOPY

• The indirect ophthalmoscope is an instrument

commonly used by the ophthalmologist.
• It produces a bright and intense light.
• The light source is affixed with a pair of binocular
lenses, which are mounted on the examiner’s head.
• The ophthalmoscope is used with a hand-held, 20-
diopter lens.
• This instrument enables the examiner to see larger
areas of the retina, although in an unmagnified state.
 SLIT-LAMP EXAMINATION

• The slit lamp is a binocular microscope mounted on a table.

• This instrument enables the user to examine the eye with
magnification of 10 to 40 times the real image.
• The illumination can be varied from a broad to a narrow beam
of light for different parts of the eye.
• For example, by varying the width and intensity of the light, the
anterior chamber can be examined for signs of inflammation.
• Cataracts may be evaluated by changing the angle of the light.
• When a hand-held contact lens, such as a three-mirror lens, is
used with the slit lamp, the angle of the anterior chamber may
be examined, as may the ocular fundus.
 COLOR VISION TESTING

• The ability to differentiate colors has a dramatic effect on the

activities of daily living.
• For example, the inability to differentiate between red and green
can compromise traffic safety.
• Some careers (.eg, color photography) may be closed to people
with significant color deficiencies.
• The photoreceptor cells responsible for color vision are the cones,
and the greatest area of color sensitivity is in the macula.
• A screening test, such as the polychromatic plates can be used to
establish whether a person’s color vision is within normal range.
• Color vision deficits can be inherited.
 CONT’D
• For example, red/green color deficiencies are inherited in
an X-linked manner, affecting approximately 8% of men
and 0.4% of women.
• Acquired color vision losses may be caused by medications
(eg, digitalis toxicity) or pathology such as cataracts.
• A simple test, such as asking a patient if the red top on a
bottle of eye drops appears redder to one eye than the
other, can be an effective tool.
• Changes in the appreciation of the gradations of the color
red can indicate macular or optic nerve disease.
 CONT’D
• The most common color vision test is performed using Ishihara
polychromatic plates.
• These plates are bound together in a booklet.
• On each plate of this booklet are dots of primary colors that are
integrated into a background of secondary colors.
• The dots are arranged in simple patterns, such as numbers or
geometric shapes.
• Patients with diminished color vision may be unable to identify the
hidden shapes.
• Patients with central vision conditions (eg, macular degeneration)
have more difficulty identifying colors than those with peripheral
vision conditions (eg, glaucoma) because central vision identifies color.
 AMSLER GRID

• The Amsler grid is a test often used for patients with macular
problems, such as macular degeneration.
• It consists of a geometric grid of identical squares with a central
fixation point.
• The grid should be viewed by the patient wearing normal reading
glasses.
• Each eye is tested separately.
• The patient is instructed to stare at the central fixation spot on
the grid and report any distortion in the squares of the grid itself.
• For patients with macular problems, some of the squares may
look faded, or the lines may be wavy.
 CONT’D
• Patients with age-related macular degeneration are
commonly given these Amsler grids to take home.
• The patient is encouraged to check them frequently,
as often as daily,
• to detect any early signs of distortion that may
indicate the development of a neovascular choroidal
membrane,
• (an advanced stage of macular degeneration
characterized by the growth of abnormal choroidal
vessels).
 ULTRASONOGRAPHY

• Lesions in the globe or the orbit may not be directly

visible and are evaluated by ultrasonography.
• A probe placed against the eye aims the beam of sound.
• High-frequency sound waves emitted from a special
transmitter are bounced back from the lesion and
collected by a receiver that amplifies and displays the
sound waves on a special screen.
• Ultrasonography can be used to identify orbital tumors,
retinal detachment, and changes in tissue composition.
 COLOR FUNDUS PHOTOGRAPHY

• Fundus photography is a technique used to

detect and document retinal lesions.
• The patient’s pupils are widely dilated during
the procedure, and visual acuity is diminished
for about 30 minutes due to retinal
“bleaching” by the intense flashing lights.
 FLUORESCEIN ANGIOGRAPHY

• Fluorescein angiography evaluates:

 clinically significant macular edema,
 documents macular capillary nonperfusion, and
 identifies retinal and choroidal neovascularization (ie,
growth of abnormal new blood vessels) in age-related
macular degeneration.
• It is an invasive procedure in which fluorescein dye is
injected, usually into an antecubital area vein.
• Within 10 to 15 seconds, this dye can be seen coursing
through the retinal vessels.
 CONT’D
• Over a 10-minute period, serial black-and-
white photographs are taken of the retinal
vasculature.
• The dye may impart a gold tone to the skin of
some patients, and urine may turn deep
yellow or orange.
• This discoloration usually disappears in 24
hours.
 TONOMETRY
• Tonometry measures IOP by determining the amount of force
necessary to indent or flatten a small anterior area of the
globe of the eye.
• The principle involved is that a soft eye is dented more easily
than a hard eye.
• Pressure is measured in millimeters of mercury (mm Hg).
• High readings indicate high pressure; low readings, low
pressure.
• The procedure is noninvasive and is usually painless.
• A topical anesthetic eye drop is instilled in the lower
conjunctival sac, and the tonometer is then used to measure
the IOP.
 GONIOSCOPY

• Gonioscopy visualizes the angle of the anterior

chamber to identify abnormalities in appearance
and measurements.
• The gonioscope uses a refracting lens that can be a
direct or indirect lens.
• The indirect lens views the mirror image of the
opposite anterior chamber angle and can be used
only with a slit lamp.
• The direct gonioscopic lens gives a direct view of
the angle and its structures.
 PERIMETRY TESTING

• Perimetry testing is used to check the field of vision.

• A visual field is the area or extent of physical space
visible to an eye in a given position.
• Its average extent is 65 degrees upward, 75 degrees
downward, 60 degrees inward, and 95 degrees
outward when the eye is in the primary gaze (ie,
looking directly forward).
• It is a three dimensional contour representing areas
of relative retinal sensitivity.
 CONT’D
• Visual acuity is sharpest at the very top of the field
and declines progressively toward the periphery.
• Visual field testing (ie, perimetry) helps to identify
which parts of the patient’s central and peripheral
visual fields have useful vision.
• It is most helpful in detecting central scotomas (ie,
blind areas in the visual field) in macular
degeneration and the peripheral field defects in
glaucoma and retinitis pigmentosa.
 METHODS
• The two methods of perimetric testing are manual and
automated Perimetry.
 Manual Perimetry involves the use of moving (kinetic)
or stationary (static) stimuli or targets.
• An example of kinetic manual Perimetry is the tangent
screen.
• A tangent screen is a black felt material mounted on a
wall that has a series of con-centric circles dissected by
straight lines emanating from the center.
• It tests the central 30 degrees of the visual field.
 CONT’D
 Automated perimetry uses stationary targets,
which are harder to detect than moving targets.
• In this test, a computer projects light randomly
in different areas of a hollow dome while the
patient looks through a telescopic opening and
depresses a button whenever he or she detects
the light stimulus.
• Automated perimetry is more accurate than
manual perimetry.