This document provides guidance on performing visual field and pupillary reflex examinations. It outlines 9 steps for visual field testing, including peripheral, central and blind spot testing. It also outlines 8 steps for pupillary reflex testing, including testing the direct and consensual light reflex, relative afferent pupillary defect and accommodation reflex. Tips are provided throughout, such as ensuring the patient can see the test object and giving precise instructions to patients. The document advises looking for additional physical signs that can help localize lesions.

1. Clinical Methods; Visual Fields &
Pupillary Reflexes
Prof. Dr. Hussain Ahmad Khaqan
 MD
 FRCS(Glasgow)
 FCPS(Ophth.)
 FCPS(Vitreo Retina)
 MHPE (KMU)
 CICO(UK)
 CMT(UOL)
 Fellowship in Medical Retina (LMU, Munich)
 Fellowship in Vitreo Retinal Surgery (LMU, Munich)
 Consultant Ophthalmologist & Retinal Surgeon
Professor of Ophthalmology
Lahore General Hospital, Lahore
Ameer Ud Din Medical College, Lahore
Post Graduate Medical Institute, Lahore
Shaukat Khanum Memorial Cancer Hospital & Research Centre ,Lahore

2. CLINICAL METHOD; VISUAL FIELDS

3. VISUAL FIELD EXAMINATION
1. Introduce yourself.
2. Quick inspection for any obvious physical
signs which may give clues to the underlying
visual field defects such as hemiplegia for
hemianopia or quadrantinopia or
acromegalic features suggestive of
bitemporal hemianopia.

4. 3. Sit yourself at least 1 metre opposite the patient
and at the same eye level for an accurate
confrontation test.
4. Make sure the patient can see the object (for
example your fingers or a white pin) which you
use to test the visual field. This is done by
getting the patient to cover each eye in turn and
present your fingers in the patient’s central field.
Tips:
• if step 3 is omitted, you may waste valuable time
testing the visual field of a blind eye!

5. 5. Begin with the peripheral visual field.
Test each eye individually starting with the
patient’s right eye. Instruct the patient to
cover his left eye and look into your right eye.
This ensures that the patient keeps his eye
still. Present your finger at each hemisphere
to test for hemianopia. Then test for
quadrantinopia by presenting your fingers at
each quadrant. Repeat with the other eye.

6. Tips:
• To avoid appearing clumsy, use your left
fingers to test the patient’s right temporal and
left nasal field, and your right fingers for left
temporal and right nasal field.
• Beware of left-right disorientation. The visual
field defect is described with respect to the
patient’s field. Also remember that a patient
with right homonymous hemianopia
(quadrantinopia) has lesion in the left cerebral
hemisphere and vice versa.

7. 6. Test the central field.
This is done with a red pin. Bring the pin
towards the centre from each quadrant and
ask the patient to comment when the pin is
seen as red. When the pin appears red ask
the patient to comment again when the red
pin is perceived as faded or disappeared as
you continue to move the pin towards the
centre.

8. Tips:
• Instruction is very important especially if you are
not dealing with a ‘professional patient’. Precise
instructions include. ‘I am going to move this red
pin towards the centre of your vision and I want
you to tell me when you can see the pin becomes
RED and NOT when it is of any other colour.’
When the red pin is seen, stop and give the
second instructions. ‘I am going to move this red
pin further in to the centre of your vision, tell me
when the pin disappears or when it becomes less
red.’ Proficiency only occurs with constant
practice.

9. 7. Test for the blind spot.
Move the red pin in the central field and ask
the patient to comment when it disappears.
Move the red pin outward in horizontal and
vertical plane until the red pin reappears.
Compare this with your blind spot for any
enlargement.

10. 8. In the absence of a peripheral or central field
defect. Suspect the presence of an early
bitemporal hemianopia. Presenting two red
objects one in each hemifield of the patient’s
eye and look for temporal colour desaturation.
Red desaturation is also a more sensitive tool to
characterize the depth of the scotoma eg. in a
bitemporal hemianopia, the superior quadrant
may be more severely affected.
9. You may be asked to elicit further clinical signs
and to support your diagnosis or localizing the
lesion.

11. Tips:
• Look for hemiplegia in the presence of hemi-or
quadrantinopia.
• In the presence of a bitemporal hemianopia,
look for systemic evidence of pituitary
abnormalities such as acromegaly.
• In constricted visual field, look for macular
diseases or pale optic disc.
• Enlarged blind spot occurs in papilledema,
myopic disc and myelinated optic disc.

12. CLINICAL METHOD; PUPILLARY REFLEXES

13. PUPIL REFLEXES
1. Introduce yourself
2. General observation is very important.
Comment on cranial scars, pulmonary apex
pathology, evidence of previous brachial
plexus injury, or thyroidectomy scars.
3. In the light, observe the eyes for obvious
anisocoria, heterochromia or ptosis (mild in
Horners, complete/incomplete in 3rd nerve
palsy) and esotropia (6th nerve palsy)

14. 4. Always examine for anisocoria in BOTH light
and dark conditions. If present, state that
‘there is an EFFERENT pathway disorder, but I
will complete my testing of pupillary reflexes
first before completing my examination of
the efferent pathway.’

15. TIPS:
• Look carefully for anisocoria. If the room is
bright, ask for the room to be dimmed and this
may bring out anisocoria when the small pupil
is abnormal.
• Heterochromia is best seen in bright light.

16. 5. In the dark, test the right pupillary reflex by
using the brightest, most even source of
illumination available to you. Observe the
direct (the eye in which the light was shown)
and consensual responses (the pupil reaction
of the fellow eye). Repeat the test with the
left eye.

17. Tips:
• Do not stand in front of the patient during the
examinations as this can stimulate miosis due
to accommodation.
• Specifically instruct the patient to fixate on a
distant target in order to relax the
accommodation.
• If the room is too bright, pupillary reaction
may be difficult to observe. Always dim the
lights.

18. 6. Test for a relative afferent pupillary defect.
Shine the light first into the right pupil, when
the right pupil constricts, quickly shine the
light into the left pupil. Observe for any initial
dilatation in the left (as well as right) pupil.
When the left pupil constricts quickly move
the light back into the right eye.
7. Test the accommodation reflex. Get the
patient to look at a distant object and then at
an object placed in front of him. Repeat and
look at other pupil.

19. Tips:
• The near object should preferably be one that
can stimulate accommodation such as a
picture or a letter on a stick. Avoid using your
finger to test accommodation.

20. 8. You should now have a differential diagnosis
of your findings. You may be asked to further
tests to narrow down your diagnosis.

21. Tips:
1. In the presence of a relative afferent pupillary
defect, the examiner may ask you to look for
further physical signs, you can choose either:
examination of the fundus for optic atrophy,
search the temporal area for temporal artery
biopsy scar or endarterectomy scar on the neck.
2. In Horner’s syndrome, look for neck scars
(following thyroid operation), ipsilateral wasting
of small muscles of the hand which can result
from a lesion at the apex of the thorax. Know
your pharmacological tests for horners pupil
testing well

22. 3. In Adie’s pupil, ask to examine the iris on slit-lamp
for vermiform iris movements and segmental
atrophy. Also ask to test the tendon reflex (knee
jerk) for hyporeflexia in Holmes-Adie syndrome
4. In traumatic mydriasis, look for segmental pupillary
rupture, traumatic cataract, phacodonesis /
iridodonesis, and unequal anterior chamber depth
(posterior segment for evidenve of previous trauma)
5. In physiological anisocoria, mention that you would
like to perform a FAT scan (family album
tomography)
6. Lastly do not forget the pharmacological tests for
anisocoria. They are very popular.